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Volunteer Application

This agency does not discriminate on the basis of race, color, religion, age, sex, national origin, political affiliation, sexual identity, or other non-performance factors. Your responses on the application are confidential.

Name     Date of Birth
Age(optional)     Sex: Male     Female
Address
City    State     Zip
Home Phone     Work Phone
Email Address
Confirm Email Address
Workplace
Occupation
Days And Hours Available To Volunteer:
Hobbies Or Interest:
How did you discover the opportunity to become an adovocate/volunteer:
Below is a list of possible volunteer activities, please check the ones you would be interested in:
Court advocacy     Office work     Resale shop     Board committees
Fund raising     Speaker’s Bureau     Household maintenance
Direct Services with women     Transportation     Children’s advocacy
Other(specify):
Past relevant experience:
Purpose in volunteering:
What qualities and skills do you have that you feel would contribute in this type of work:
What are your feelings toward a woman who elects to remain in a violent situation:
Often children from violent homes repeat behavior they have witnessed (i.e. verbal and physical abuse). Describe your reaction toward a child who may chose to repeat aggressive behaviors in your presence:
Any comments or questions:
Have you ever been convicted of a criminal offense: Yes     No
If yes, state:

Please list two (2) references (Name, Address, Relationship, Home/Work Phone):
Reference #1
Reference #2

Who to contact in case of emergency (Name, Address, Relantionship, Home/Work Phone):
Person #1
Person #2

I certify that the above statements are true and correct to the best of by knowledge and belief. I understand that willful misrepresentation or omission of facts may prevent my serving as a volunteer. I release all persons and agencies from any and all liability which may be incurred as a result of obtaining and using this information.

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