Conestoga View Volunteer Application

This application should be completed as part of the orientation process and not to find out more information about becoming a volunteer. If you would like more information about volunteering at Centre Care, or you would like to find out when our next Volunteer Orientation is happening, please contact us at (814) 278-6000.
Last Name*
First Name*
Middle Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
(Information obtained regarding age is used only for legitimate business purposes and not in violation of any state or federal laws.)
Email*
example@example.com
Home Phone*

Area CodePhone Number
Work Phone*

Area CodePhone Number
Special Interests (Please check all that apply)*

Arts/CraftsBus TripsCards/GamesComputersExercise/SportsMusicVisitingSpiritual CareHolidaysOther
Reason for volunteering (Please check all that apply)*

School RequirementCommunity Service RequirementSummer Youth ProgramMinistryAuxilaryOther
Name of School (If school requirement)
Grade Level (If school requirement)
Required Hours (If school requirement)
Please Select Appropriate (If Community Service requirement)

AdultJuvenile
Required Hours (If Community Service Requirement)
When are you available to volunteer?*

Weekday MorningsWeekday AfternoonsWeekday EveningsWeekend MorningsWeekend AfternoonsWeekend Evenings
Have you ever been exposed to or tested positive for TB (tuberculosis)?*

YesNo
Did you receive a seasonal flu shot?*

YesNo
Personal References
Name*
Phone Number*

Area CodePhone Number
Name*
Phone Number*

Area CodePhone Number
Emergency Contact

In case of an emergency please notify:
Name*
Relationship*
Home Phone*

Area CodePhone Number
Work or Cell Phone*

Area CodePhone Number
Agreement
I agree to abide by the policies and procedures of Centre Care as stated in the Volunteer Guidelines Packet given to me at my orientation. I have informed the Centre Care Volunteer Office of any medical situations that may require accommodations to fulfill my Volunteer Service. I certify that I am free from communicable diseases. I will keep Centre Care informed of any changes in my condition. I will not hold Centre Care responsible for any accidents, injuries, or loss of personal property. By clicking "Submit," you agree to these terms.
Please Complete If Under 18 Years of Age
I give permission for my child to volunteer at Centre Care. I will encourage my child to read and abide by the information provided in the Volunteer Guidelines Packet provided to us. By clicking "Submit," you agree to these terms.
Parent/Guardian Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Work or Cell Phone

Area CodePhone Number
Email Address
example@example.com
Should be Empty:

Personal References

Emergency Contact

Agreement