Volunteer Information Form
1. Personal Information (The "*" indicates a required value)
Are you at least 18-yrs. old?
 Name: *
 
 
Home Address: *
City/Town: *
ZIP Code: *
(Street Number/Name, Rural Route, P.O. Box #)
Home Telephone #: *
Work Telephone #: *
E-Mail Address: *
The following information will only be used if a background check is required for the volunteer job you will be performing.
Birthdate: (mm/dd/yyyy) 
DL or State ID #: 
2. Volunteer Survey
 
hours of volunteer service for:    


   

Please list any special accomodations that you may need to participate in volunteer opportunities: 

Please list days and times you are available:
3. Interests and Skills
I am interested in volunteering in the following areas (check as many as apply):



      
      
      
      
      
      
      
      



      
        

      
      



      
      
      
      
      
      
          
          
          
      






 

Please list any skills or talents that you think might be useful:

 
4. Employment Experience - Start with your present or last job. (Fill this section out only if asked by NCCS staff)
Job #1
Employer:
Length of Service: 
Work Performed: 
Phone #: 
Job Title: 
Supervisor:
Reason for Leaving (if applicable):
Job #2
Employer:
Length of Service: 
Work Performed: 
Phone #: 
Job Title: 
Supervisor:
Reason for Leaving (if applicable):
5. Volunteer Experience - Start with your present or last experience. (Fill this section out only if asked by NCCS staff)
Experience #1
Agency/Organization:
Length of Service:
Work Performed: 
Phone #: 
Job Title:
Supervisor:
Reason for Leaving (if applicable):
Experience #2
Agency/Organization:
Length of Service: 
Work Performed: 
Phone #: 
Job Title:
Supervisor:
Reason for Leaving (if applicable):
 
6. Disclosure Statement
Have you ever been convicted of a crime? 
   
To the best of my knowledge, the information on this sheet is true and accurate. I give NCCS my permission to check any references I have listed and perform any other background checks as necessary. I authorize NCCS to disclose pertinent information to other agencies, organizations, churches or individuals for the purpose of sharing volunteer information. I release NCCS from any liability for use of images which include myself or family members generated for public relations purposes including but not limited to; printed publications, videos, TV, internet, and web site.
*Do you agree with the above Disclosure Statement? 
*By selecting 'Yes', you are effectively applying an "electronic signature" to your consent of the above Disclosure Statement in Section 6 (labeled "Disclosure Statement").
 
© 2008 NCCS | 6308 S. Warner Ave PO Box 149 | Fremont, MI 49412 | Phone: (231) 924-0641 | Fax: (231) 924-5594