Providence House · Volunteer Application

Contact Information

Name *

First Name

Last Name

Email *

Verify Email *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Date of Birth *

(mm/dd/yyyy)

Phone *

Emergency Contact:

Skills and Interests:

Educational and Experience Background

Current or Recent Occupation:

Hobbies, Interests, Skills:

Previous Volunteer Experience:

Topics I can teach:

If selected other, please describe:

What age group(s) do you have experience with and/or are interested in working with? *

Adult women

Children

Infants

Preschool

Elementary

Availability

At what times are you available to volunteer?

Flexible

Weekdays

Weekends

Evenings

Other

If selected other, please describe:

Personal Data

**We will need a copy of a government issued ID (such as a driver's license).

Government Issued ID

If you have a digital copy of your government issued ID, you may upload it here.

Do you have access to an automobile you can use for volunteer work? *

Do you possess a valid driver's license? *

If yes, what state:

Have you ever been convicted as an adult of a misdemeanor or felony, including all traffic violations?

If yes, please explain:

References

List the names, addresses, phone numbers, and email addresses (if applicable) of three personal references, other than relatives:

Reference #1

Reference #2

Reference #3

Client Confidentiality/Protection Pledge/Emergency Treatment

Please read the following statement carefully:

Maintaining the confidentiality of the residents of Providence House and their families is of the utmost importance. As a volunteer, you will be expected to abide by this organization's policy to protect the confidentiality of those who live here. In agreement with this policy, I pledge to honor the privacy and uphold the confidentiality of each resident/child at Providence House. Providence House reserves the right to obtain a criminal background and social security number check. If I should become ill/injured, I authorize Providence House to arrange emergency treatment and I accept responsibility for payment of medical services rendered.

Signature: *

Please type your name as your digital signature.