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LONG-TERM VOLUNTEER APPLICATION
Full Name:
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Address:
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City:
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State:
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Zip:
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Phone #:
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Email:
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Date Available:
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Position applied for:
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Are you a citizen of the United States?
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Yes
No
If no, are you authorized to work in the U.S.?
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Yes
No
Education
High school:
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Address:
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From
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To
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Did you graduate?
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Yes
No
College:
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Address:
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From
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To
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Did you graduate?
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Yes
No
Other:
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Address:
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From
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To
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Did you graduate?
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Yes
No
Experience and Skills
Do you have any previous experience working with people with disabilities? (if yes, please describe)
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List any relevant skills
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Why are you interested in volunteering with Misericordia?
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Short answer: Describe a time when you helped someone overcome a challenge. What did you learn from that experience?
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Part of your work will be to assist residents in their daily work opportunities (this is referred to at Misericordia as DT - Developmental Training). Please choose which sites are of most interest to you:
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Arts & Crafts
Greenhouse (plants)
Recreation Department
Art Mentor
Light housekeeping
Recycling
Bakery/Packaging
Music
Religious Programming
Ceramics/Painting
Office Skills
Restaurant
Fitness/Team Sports
PT/OT/Speech Therapy
Teaching
References
Please list three professional references.
Full Name:
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Relationship:
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Company:
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Address:
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City:
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State:
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Zip:
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Phone #:
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Email:
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Full Name:
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Relationship:
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Company:
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Address:
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City:
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State:
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Zip:
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Phone #:
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Email:
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Full Name:
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Relationship:
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Company:
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Address:
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City:
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State:
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Zip:
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Phone #:
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Email:
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Previous Employment
Company:
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Supervisor:
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Phone:
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Address:
City:
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State:
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Zip:
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Job Title:
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From:
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From:
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Responsibilities:
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May we contact your previous supervisor for a reference?
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Yes
No
Company:
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Supervisor:
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Phone:
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Address:
City:
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State:
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Zip:
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Job Title:
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To:
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To:
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Responsibilities:
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May we contact your previous supervisor for a reference?
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Yes
No
Company:
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Supervisor:
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Phone:
*
Address:
City:
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State:
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Zip:
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Job Title:
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From:
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To:
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Responsibilities:
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May we contact your previous supervisor for a reference?
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Yes
No
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:
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clear
Date:
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