Volunteer Application Form
CONTACT INFORMATION
First Name:
*
Middle Name:
Last Name:
*
Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email Address:
*
example@example.com
Home Phone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Experience
Employer:
Occupation:
Working Hours:
Briefly describe the type of work you do:
Education Level:
High School
2 Year College
4 Year College
Post Grad
Foreign languages spoken:
Religious Affiliation: (Optional—this assists us in proper placement of our volunteers. We serve patients regardless of religious affiliation).
Catholic
Protestant
Jewish
Other
Personal Information:
How did you hear about us?
Why do you wish to be involved in BCSC volunteer work?
What organizations or clubs do you belong to? Are there special skills you wish to share in your volunteer work?
Do you have available transportation for your volunteer work?
Yes
No
Do you have a valid California driver's license?
Yes
No
Do you have automobile liability insurance? (Auto insurance is required if you use your car for volunteer work)
Yes
No
Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify you from volunteering.)
Yes
No
List experiences you believe would be helpful to you in BSCS volunteering, i.e., schooling, work, volunteer experience, office skills, creative arts, etc.
Areas of Interest:
(please check areas of interest)
Home-based:
Participant and/or family visits
Shopping/errands
Read to participant
Homemaking chores
Write letters
At the Center:
Sewing/crafts
Computer work
Office assistance
Multiple Cultural Activities
Music or entertaining
Pet Therapy
Greeting New Participants
Companionship
Other
Third Parties
References: (with phone numbers) Please list two.
In Case of Emergency:
Name:
Relationship:
Home Phone #:
Format: (000) 000-0000.
Work Phone #:
Format: (000) 000-0000.
Physician
Office Phone #:
Format: (000) 000-0000.
SEND
Should be Empty: