Date received: _____________
LGBT FOCUSED RESIDENCE
VOLUNTEER APPLICATION Name ________________________________________ Preferred ______________________ First Last Address _____________________________________________________________________ Street City State Zip Daytime Phone ________________________ Evening Phone _________________________ Email __________________________________________DOB_________________________ mm/dd/yyyy
Is it okay to leave a message at: The best way to contact me is
Home Phone
Work
Cell
Email
Email
Preferred Pronoun (i.e. he, she, ze, they, etc): _______ Emergency Contact: ______________________________ Phone _______________________ Are you a returning volunteer?
Yes
No
How did you hear about the Volunteer Program at Mary’s House for Older Adults, Inc.? ______________________________________________________________________________ _____________________________________________________________________________ Why do you want to volunteer at Mary’s House for Older Adults, Inc.? _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ Tell us about yourself. What do you feel makes you a good fit for Mary’s House for Older Adults, Inc.’s volunteer program? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Revised 01/14
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Which volunteer Committee/Activity are you interested in? (check all that apply) Web Development/Maintenance
Accounting
Property Maintenance
Marketing
Fundraising: Events
Major gifts
Planned Giving
Campaigns
Grants
Program Development
Special
In-kind support
Corporate
Public Relations
Federal
Pro Bono Professional Service Specialty: __________________________________
----------------------------------------------------------------
Administrative/Office
Volunteer Management
Risk Management
Community Outreach & Education
Building Contractors
Project Management
Architects
Policy
Real Estate
Grant Developer
DC Government
Do you have any past volunteer experiences? If so, please provide the name(s) of the organization(s) as well as a brief description of what you did. Organization
Position/Tasks
Dates
Do you have any other special skills or professional certifications that might benefit our clients or organization (i.e. Legal, Capacity Bldg., Marketing, Web, IT, etc.)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Below, please list your general availability. Please remember that our volunteers are expected to commit to at least 4 hours per month. Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
When is the best time to reach you? We may have questions about your application or background check; let us know which of the following time frames is best to contact you. Wednesdays 10am – 12pm
Thursdays 10am – 12pm
Other _______________________________________________ Revised 01/14
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Time Commitment I understand that participation as a Mary’s House for Older Adults, Inc. Volunteer requires a minimum time commitment of four hours per month, and that I am to notify the Chair if and when I wish to discontinue volunteering with or without reason. _________ Initial Here
Insurance Information I understand that all volunteers must agree to allow Mary’s House for Older Adults, Inc. to run a base security check for insurance purposes. _________ Initial Here I understand that Mary’s House for Older Adults, Inc. does not insure drivers; my own insurance covers myself, my vehicle, my passengers, and all other damages during volunteer activities. _________ Initial Here
Confidentiality Statement I, _____________________________________________, am volunteering my time to work with Mary’s House for Older Adults, Inc. I understand that in the course of my volunteering I may learn information about an individual or the organization that is personal and confidential. Examples of such information include organizational strategies and finances, as well as individuals’ sexual orientation, economic status and relations with family/friends. I understand that all information must be treated as completely confidential. I agree not to disclose any information of a personal and/or confidential nature to any persons not affiliated with the Mary’s House for Older Adults, Inc. management without the specific written consent. I agree that if I have any doubt about a situation I will contact the President of Mary’s House for Older Adults, Inc.
_____________________________________________________ Signature
Revised 01/14
________________ Date
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