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Personal Information

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Personal Information
Name: ____________________________________________________________________________________________________
Address: ________________________________________________________ City: ____________________________________
State: _______________ ZIP: _____________________
Work phone: _____________________________________Cell phone: ____________________________________________
Email: _____________________________________________________________________________________________________
Work and Education Experience
Please select the option that best applies to your current employment status:
Currently employed Currently between jobs Student I am retired
Current job position/title: ________________________________________________________________________________
Current employer: ________________________________ Duration of employment: From: _________ To: _______
Does your employer allow for time off to volunteer? ______Yes _____ No
Education:
Please indicate below the school you are attending, your year in school, degree you are seeking, and
approximate graduation date.
________________________________________________________ College/ University _________________________ Year
_____________________________________________________ Degree ___________________________ Graduation Date
Are you currently a student? ______Yes _______No
Please list any other degrees you have:
_________________________________________ Degree ______________________________________College/University
_________________________________________ Degree ______________________________________College/University
References
Please list 2 non-family reference whom we might contact:
Name: ________________________________________________Phone:_____________________________________________
Name: ________________________________________________Phone: ____________________________________________
Volunteer Application
Availability (some volunteer opportunities require a minimum time commitment)
Please indicate your availability below:
Weekdays 9 AM till 5 PM
____ Monday _____Tuesday _____Wednesday _____Thursday _____Friday
Weeknight and evenings 5 PM till 11 PM
_____ Monday _____Tuesday _____Wednesday _____Thursday _____Friday
For students only:
Are you volunteering as part of a class project or requirement? If so please state the class or project
requirments:________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Skills and Interests
Please indicate your experiences/skills:
____Advocacy/Civil Rights
____Children’s Programs (Art Therapy/Child Care)
____Community Outreach/Education
____Counseling
____Event Planning/Coordinating
____Fundraising
____Finance
____Grant Writing
____Hotline
____HTML/Web Design
____Life Skills (stress management, self-sufficiency
skills, job readiness, resume)
____Maintenance
____Social Media
____Volunteer Relations
Other:
__________________________________________________
__________________________________________________
__________________________________________________
Please include any certifications or trainings relevant to volunteering with us: _________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________.
As a volunteer you will be working with clients of many different ethnic and socioeconomic
backgrounds. Clients may have values and beliefs quite different from your own. Please describe why
this will or will not
present a difficulty or adjustment for you as a volunteer. ____________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________.
Volunteer Opportunities
Please help us match you with assignments you would enjoy. Please indicate the types of volunteer
services that are of interest to you (check all that apply).
24 Hour Crisis Hot Line
A
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m
inis
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a
t
i
ve
Du
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Children’s Department
Court Companion Program
Development/Fundraising
Donations Sorter
Education and Outreach
Finance
Landscaping/Maintenance
Research or Individual Projects
Shelter Shopper
Social Media/Marketing
Special Events
_____Transportation
Are there specific tasks that you are unable to perform due to physical limitation or personal
preference? Yes No __ If yes, please explain: ________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________.
Have you volunteered with us before? Yes ______ No _____ . If Yes, please explain why you stopped
volunteering. _____________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________.
What are your goals as a volunteer?
School Credits Internship Seasonal Resume Enhancement
Corporate Sponsorship Contribution to Community Court Ordered
Church Outreach Socialization Other: _________________________________________
Background Verification
Have you ever been convicted of a criminal offense? Yes No
Please explain:______________________________________________________________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________.
Have you ever been charged with neglect, abuse or assault? Yes No
Please explain: _______________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________________________________________________________.
Has your driver’s license ever been suspended or revoked in any state? Yes No
Please explain: _______________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________________________________________________________.
Do you use illegal drugs? Yes No
Please explain: _______________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________________________________________________________.
Emergency Contact Information:
Name: _______________________________________________________ Relationship:_________________________________
Phone: __________________________________ Email Address____________________________________________________
How did you hear about us?
Social Media (Facebook, Twitter, Instagram, Web page) ______
Referred by friend/volunteer ______ School/Teacher ______ Community Forum ______
TV/Radio ______ Newspaper _____ Church _____ Work _____ Other: _____
Terms and Agreements
Our volunteer program may need to do one or all of the following background screenings (Criminal
Background, Child Protective Service Record, Sexual Offender Record and Driving Record). If so, all
information, as well as all information on this application will be kept confidential and measures will
be taken to protect your privacy. To do the screenings social security number and date of birth will be
needed.
I hereby certify that the information contained in this application is true and correct to the best of my
knowledge and belief. I further consent for Samaritan House to obtain additional information
necessary to process my application. This may include but is not limited to employment verification,
references and background checks. (Please note your refusal may exclude you from consideration
from
volunteering with Samaritan House).
Name:____________________________________________________ Today’s Date:__________________________________
Social Security Number: _________________________________________Date of Birth:______________________________
Thank you for your interest in Samaritan House
Mission: To foster personal safety, self-sufficiency and personal growth in adults and their children through
freedom from domestic abuse and homelessness.
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Completed 11 April 2021

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