Volunteer Application

Name:

Address:

City:

State:

Zip:

Home phone:

Cell phone:

Email:

Website (if applicable):

Employer

Gender:

Male Female

Age:

Emergency contact:

Relationship:

Phone number:

How would you like to be involved in A Room to Heal?
(check all that apply)

	Room project
	Join a committee:
	Office assistance / administrative
	Special events
	Other (please specify):

I am available to volunteer:

Monday Tuesday Wednesday Thursday
Friday Saturday Sunday

Daytime - A.M. Hours Daytime - P.M. Hours
Evening Hours

I would prefer:

One-time opportunities Short-term opportunities
Long-term opportunities

How did you learn about volunteer opportunities at A Room to Heal?
(check all that apply)

	Word of mouth (through friends, family members, other volunteers)
	Personally asked to volunteer by A Room to Heal
	News media (Press & Sun, WBNG, etc.)
	Social media (Facebook, Twitter)
	Other (please specify):

What skills (work experience, life experience, hobbies, education) are you interested in sharing? (check all that apply)

	Office assistance / administrative		Grant writing
	Interior design		Finance / bookkeeping
	Painting		Public relations / communication
	Fundraising		Medical (nursing)
	Experience working with youth		Social work
	Strategic planning		Nonprofit (board, program director, etc.)
	Architecture		Construction
	Other (please specify):

Briefly describe your skills (ex. ADA renovations, etc.):

Please indicate any special interests or talents as well as any personal goals or concerns:

Please list two references:

Have you ever been charged with a felony? Yes No

If yes, please explain:

Due to the nature of our work, A Room to Heal reserves the right to conduct a background check on all individuals interested in volunteering.

Electronic Signature:

Type your full name:

Today's date:

Parent or guardian
(if under 18):