ARKANSAS DEPARTMENT OF HEALTH AND HUMAN SERVICES

ARKADELPHIA HUMAN DEVELOPMENT CENTER

VOLUNTEER APPLICATION

Fall ________ Spring ________

Personal information:

Name:_____________________________     Phone (H):_____________ (W):_____________

Address:___________________________        Email:___________________________________

                ___________________________     Religious affiliation (optional):________________ Occupation:________________________        ________________________________________

Affiliation:

_____ HSU, Instructor _________________________  Phone Number ___________________

_____ OBU, Instructor _________________________  Phone Number ___________________

_____ Other, Please list ________________________________________________________

Present Situation: Employed ___ Retired ___ Unemployed ___ Student ___ Other _________

Volunteer options:

___Mentoring                   ___Crafts     ___Horse Riding     ___Grounds     ___Adult Enrichment

(See Volunteer Brochure for what these options entail.)         

Placement preference:

Please check all that apply:

I can volunteer:     ___once a week      ___more than once a week      ___as needed   ___other

Matching information:

General interests, skills, volunteer experience, languages, and hobbies:___________________

____________________________________________________________________________

____________________________________________________________________________

Screening information:

Do you have a valid driver’s license?               ___yes                            ___no

              License number:  __________________________

              Insurance company: ________________________  Policy number:_________________

Have you ever been convicted for violation of any laws, traffic or otherwise?  ___yes   ___no

              If yes, please explain:_____________________________________________________

I am willing to drive: ___My Vehicle  ___ a State Vehicle

Do you have any physical condition that may limit your volunteer activities?  ___yes   ___no

              If yes, please describe:____________________________________________________

Emergency contact:

Name:_______________________     Phone:_________________   Relation:_______________

References:

Please list three persons we may contact who are not family members.  You may include employers, teachers, religious leaders, or others whose relationship to you is more than a personal friend.

Name:_______________________     Phone:_________________   Relation:_______________

Address:_____________________________________________________________________

Name:_______________________     Phone:_________________   Relation:_______________

Address:_____________________________________________________________________

Name:_______________________     Phone:_________________   Relation:_______________

Address:_____________________________________________________________________

I hereby give my consent for the Arkadelphia Human Development Center to contact my references: to contact my employers, past and present; and to conduct a routine police check.

_____________________________________                          ________________

Signature of Applicant                                                                         Date