Name

Street Address

City

State

County

Zip

(xxx) xxx-xxxx

Email Address

Preferred Method of Contact Preferred Method of Contact Phone SMS/Text Email

Date of Birth

Gender Gender Male Female Non-Binary

Emergency Contact

Relationship

Address

Primary Phone

Have you ever been arrested or convicted of a criminal offense, other than minor traffic violations? Have you ever been arrested or convicted of a criminal offense, other than minor traffic violations? Yes No

If yes, please explain.

Please list any health conditions that affect your volunteer work - including any head, neck, back, joint, or heart issues, and any allergies. Please notify and inform a staff person if any protocol is required in case of an emergency, such as epi-pen injections, insulin shot, etc.

What experience do you to hope to gain through volunteering?

Do you have any personal experience with domestic violence? Do you have any personal experience with domestic violence? Yes No

Availability Availability Weekday Mornings Weekday Afternoons Saturday Mornings Saturday Afternoons

Understand Understand I understand that by submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal. I also understand that by checking this box it is the same as signing my name per the Electronic Signatures in Global and National Commerce Act (ESIGN, 2000) and the Uniform Electronic Transactions Act (UETA, 1999).

Additional Comments