FIELDS MARKED WITH * ARE REQUIRED!

Name:*               
                   (First)          (MI)  (Last)
Address:*          
City:*             
State:*            
Zip:*              
Date of Birth      
 
January
February
March
April
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June
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August
September
October
November
December
/
 
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/
1991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943 

E-Mail Address:*   


Employer:          
Employer Address:  
Employer City:     
Employer State:    
Employer Zip:      


Phone:
                  (########## all 10 digits without () or -)
Home:*             
Work:              
Other:             


Religious/Civic/Professional Affiliations:

                   

Where did you hear about our volunteer program?

                   

Are you in school? Yes No

If "yes" Where?    

Educational Degrees / Training:

                   

Would you have a problem being fingerprinted? Yes No

Do you have any limitations that would preclude you from performing any work for
which you are being considered?	Yes No

If yes, Please explain

                   

Why would you like to volunteer for Faith House?

                   

Have you ever volunteered at another agency?  Yes No

If yes, where and what were your duties?

                   

What days and times are you available to volunteer?

                   

How many hours a week can you commit?

                   

Do you personally know someone who, has been or is currently a victim of
Domestic Violence?      Yes No

If no, do you have any knowledge about victims of domestic violence?

		     

If you have ever been a victim of abuse, you may encounter a resident who has had an
experience similar to your own. Realize this may bring back memories of your abuse
List three references (not family members).  At least one should be a professional reference
such as an employer, clergy person, etc. Reference letters will be sent; therefore we ask that
you supply ALL information. (Be sure to include all numbers, street, apt, zip, etc.)

Reference One:


Name:              
Phone:             
Street Address:    
City/State/Zip:    
Relationship:      


Reference Two:


Name:              
Phone:             
Street Address:    
City/State/Zip:    
Relationship:      


Reference Three:


Name:              
Phone:             
Street Address:    
City/State/Zip:    
Relationship: