Maintenance Volunteer Registration Form

Maintenance Volunteer Registration Form

Please let us know your availability and areas of interest
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Are you 18 years or older?*

YesNo
Will you be receiving school credit or fulfilling graduation requirements?*
Emergency contact and phone number*

Preferences in Area of Volunteering*

	Would love to!	Would like to.	Wouldn't mind helping.	Not this area.
General repairs like changing lights, replacing outlets, doorknobs and doors
Electric repairs
Plumbing repairs
Set up/take down chairs in the auditorium
Set up/take down special museum displays
Wash tablecloths
Clean windows
General clean up inside the museum
Clearing exterior drains and stairwells of leaves and debris
Collecting and removing debris, sticks and limbs from the grounds
Weeding and tending to the flower beds
Fixing the brick sidewalk

Weekly Availability *

	Wednesday AM	Wednesday PM	Thursday AM	Thursday PM	Friday AM	Friday PM	Saturday AM	Saturday PM
Best for me
Not Available

Please list 3 references*

Emergency Medical Information (Please list any allergies, medications needed in the event of a reaction and any major medical conditions)*
Have you ever been charged with, convicted of, or pled guilty to a crime, either a misdemeanor or a felony (including but not limited to drug-related charges, child abuse, other crimes of violence, theft, or motor vehicle violations)?*

YesNo
If yes, please explain.
I, _________________, allow the Berks History Center to run a background check that includes child abuse clearance. *

Clear
*PERMISSION from parent or guardian REQUIRED for youth under 18 years of age: ________________ has my permission to volunteer at the Berks History Center.

Clear
Should be Empty: