Volunteers

Name

Street Address

Home Phone

City, State and Zip Code

Email Address

Emergency Contact Name/Relationship

Emergency Contact Phone

How did you hear about Trillium House?

Would you like to be added to our mailing list? Would you like to be added to our mailing list? Yes, please No thank you

Why are you interested in serving as a Trillium House volunteer?

Are you currently employed? Are you currently employed? Yes No

Current or Most Recent Company/Organization

Company/Organization Phone Number

Start Date Month/Year

End Date: Month/Year

Company/Organization Street Address

Company/Organization City, State and Zip

Job Title

Job Duties

Licenses/Certifications

OK to call me at work? OK to call me at work? Yes No

Volunteer Experience #1 (include organization name, services performed and dates of service)

Volunteer Experience #2 (include organization name, services performed and dates of service)

Volunteer Experience #3 (include organization name, services performed and dates of service)

Personal References #1 (include name, phone, email address, relationship

Personal References #2 (include name, phone, email address, relationship

Personal References #3 (include name, phone, email address, relationship

Volunteer Role Preferred Volunteer Role Preferred Care Support Friend Visitor Handyperson Administrative/Clerical Assistant Gardener/Outdoor Volunteer Coordinator

Would you be able to commit to volunteer for at least 6 months? Would you be able to commit to volunteer for at least 6 months? Yes No Unsure

Number of Days a Week

Preferred Days Preferred Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Number of Times a Month

Time of Day Time of Day Morning Afternoon Evening Night

Are you Interested in Being On-Call? Are you Interested in Being On-Call? Yes No

Have you ever been found guilty, pled no contest, or had a conviction for any criminal act other than a minor traffic violation? Have you ever been found guilty, pled no contest, or had a conviction for any criminal act other than a minor traffic violation? Yes No

If yes, please explain

Do you have any health conditions that require special precautions when in personal contact with others? Do you have any health conditions that require special precautions when in personal contact with others? Yes No

If yes, please explain