Legal Name
*
First Name
Last Name
Phone Number
*
Date of Birth
*
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Month
-
Day
Year
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Best Time to Call
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-Shirt Size
Please Select
Small
Medium
Large
XL
2X
3X
Place of Employment
School/ Organization
Marital Status
Best time/types of ways you would like to volunteer?
Events/Fundraisers
Evenings Mon- Fri
Weekends
Office /Virtual Opportunities
Programs /Adult
Programs /Children
Ombudsman
Other
How Often Would You Like To Volunteer
Every Week
Once a Month
Twice a Month
Episodic/Special Events
Other
Which county would be best for you to provide volunteer service
Please Select
Franklin
Ross
Lawrence
Scioto
Briefly Describe your interest in volunteering with our organization?
*
Have you worked previously with Adults/ Children with disabilities?
List any Leadership/Volunteer experiences You Have previously participated
Have You Ever Been Accused, Charged With, or Alleged to Have Committed Any Act of Neglect, Abuse, or Molestation Against A Minor/Adult? If Yes, Explain in Detail, Providing Date and Place of Incident:
*
Local Personal References (Must Be 18 Years Old and Not Related to You)
Reference Name
*
First Name
Last Name
Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference Name
First Name
Last Name
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I hereby authorize Easterseals to verify all information contained in this application with any references, my past or present employers, any other appropriate personnel at my past or present employment, churches or other organizations, and any individuals. I authorize those who are contacted to disclose any and all information .
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