LeadUS Mentoring Program 2015-16

VHF Volunteer & Committee Interest Form

For Questions Contact, Kelly Waters at 804-740-8643 or info@vahemophilia.org
Date*

MonthDayYear
Date
Personal Information
Name*

First NameLast Name
Salutation
Example: Mr., Mrs., Ms., Dr.
Pronouons
Example: He/Him, She/Her, They/Them
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Home Phone
Birth Date*

MonthDayYear
Business/School Information
Profession
If you are a student, please write "student"
Name of Business and/or School
Have you ever been involved with other non-profit organizations?*

YesNo
If yes, please list organizations and type of involvement.*
Additional Information
Please describe any experience you have had as a community member, donor or volunteer with VHF. How many year(s) have you been involved in some capacity?*
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. As well as any current certifications, such as CPR and First Aide.*
Any additional information you feel would be helpful to share? *
Are you interested in volunteering on a VHF committee?*

YesNo
If yes, please indicate which committees you would be most interested in joining*

AdvocacyDevelopmentFinanceFinancial AssistanceProgramScholarshipOther
Please explain your choices*
References

Please list two people, not related to you who have knowledge of your qualifications.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship*
Background Check
Have you ever been convicted of a crime other than a minor traffic violation?*

YesNo
If yes, please explain.*
I certify, by my electronic signature, that the facts set forth in this application are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I consent that VHF may complete a criminal background check prior to my volunteering.
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Date*

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Date
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VHF Volunteer & Committee Interest Form

Personal Information

Business/School Information

Additional Information

References

Background Check