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Confidential Event and Office Support Volunteer Application

(This information is confidential and will be used only at HALSA)

NOTE: Answer only those questions that you feel comfortable answering.

DATE: ___________________                                                                

CONTACT INFORMATION

Date of Birth: ______________                                               Sex: [  ] M   [  ] F   [  ] Transgender

Name: _________________________________________________________________________

Home Address: __________________________________________________________________

City: ____________________________________  State: ______   ZIP Code: ________________

Home Phone: ________________________________________ Best Time to Call ___________

Business Phone: ______________________________________ Best Time to Call ___________

Cell Phone: __________________________________________ Best Time to Call ___________

May we send mail to the above address?

[  ] Yes   [  ] No

May we leave a message at either of the above phone numbers?

[  ] Yes   [  ] No

Email Address:                                                 May we send email at this address?    [  ] Yes   [  ] No

By listing your e-mail address with HALSA, you will be automatically be added to a database that will send you e-mail regarding issues of importance to the HALSA community. If you don’t want to receive e-mail that will link you directly to HALSA, or if you are concerned about HALSA appearing in your e-mail history log at work, please DO NOT fill in the e-mail address above.

VOLUNTEER INQUIRY

I am available: [  ] Day   [  ]Evenings   [  ] Weekends   [  ] Events  [  ] Special Projects

I’m interested in finding out about the following areas: _______________________________________

SKILLS I WOULD LIKE TO OFFER HALSA

If YES, what did you do and when? _______________________________________________________

Any previous Volunteer work experience? [  ] Yes  [  ] No _____________________________________

____________________________________________________________________________________

EMERGENCY CONTACT INFORMATION

Emergency Contact Name:                                                       Relationship: ____________________

Phone Number: ___________________    Any Health Alerts in case of emergency? _________________

Are you a student?     [  ] No              [ ] Yes:  [  ] High School   [  ] College: ___________________

Employment status:    [  ] Full-time      [  ] Part-Time    [  ] Retired

Employer: __________________________________________________________________________ 

Does your employer provide an employee matching incentive?     [  ] Yes   [  ] No

Occupation: _________________________________________________________________________

MISCELLANEOUS

Is this for Court Ordered Community Service:

[  ] Yes   [  ] No

Have you even been convicted of a felony?

[  ] Yes   [  ] No

Are you a HALSA Client?                                  [  ] Yes             [  ] No  

If yes, are you currently under a service agreement? (Please explain)                                                      

Have you recently experienced a major life change (work, relationship, death of a loved one,etc?)              

                                                                                                                                           ________

Are there any limitations or commitments that would restrict your work at, or prevent you from making a commitment to HALSA? _________________________________________________________________________

Other than English, what languages do you speak (Include ASL skills)

___________  [  ] Native Speaker;  [  ] 2^nd Language;  [  ] Translator;  [  ] Teacher;  [  ] Interpreter

___________  [  ] Native Speaker;  [  ] 2^nd Language;  [  ] Translator;  [  ] Teacher;  [  ] Interpreter

For Office Use Only:

Orientation Date:

Program Interest:

Start Date:

1.

TB Test: Yes, No      Driver’s License: Yes,  No

2.

Intern: Yes, No          Start:                  End:

3.

Intern Supervisor:

4.

I.S. Training needed?   Yes,   No

I.S. Training Completed