Modus · Modus Volunteer Application

Personal Information

Name

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First Name

Last Name

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email

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Verify Email

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Join our mailing list?

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Primary Phone

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Text Notifications

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Select all that apply.

Primary phone receives text messages.

Alternative phone receives text messages.

I cannot receive text messages.

Alternative Phone

How did you learn about Modus?

*

If "other", please specify.

Are you over the age of 21?

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Do you have a valid Driver's License & Vehicle Insurance?

*

Do you have a smartphone or mobile device with a touch screen?

*

Do you have a reliable vehicle?

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Preferred Method of Contact?

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Special accommodations or supports needed?

Authorization

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 could invalidate my participation in the program. The undersigned authorizes Modus to secure any information from sources referred to or inferred herein or sources which the agency deems necessary to evaluate the undersigned potential as a Modus volunteer, including criminal background checks. All information will be held in strict confidence. The undersigned acknowledges and agrees that 1) he/she is not obligated, if called upon, to perform the volunteer services herein applied for and that the agency is not obligated to assign or place the undersigned to a volunteer position and 2) further training, orientation, and reading may be required by the agency before placement. I give permission for photos and videos of me during the course of volunteering for Modus.

Electronic Signature

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First Name

Last Name

Date

*

(mm/dd/yyyy)