| Name: |
(required) |
Group Name
(If applies) |
|
| Address |
(required) |
| Address |
|
| City |
(required) |
| State |
(required) |
| Zip |
(required) |
| Home Phone |
(required) |
| Work Phone |
|
| Cell Phone |
|
| Email |
(required) |
| Date of Birth |
(required) |
| Current Occupation |
|
| Employer |
|
| What languages do you speak? |
|
| Volunteer Experience |
(required) |
| What days and hours will you be available to volunteer? |
| Mornings 8am to 12 |
|
| Afternoons 12 to 5pm |
|
| Evenings 5pm- 8pm |
|
| Are you seeking to complete court appointed volunteer hours? |
|
(required) |
| If "Yes", the number of hours you need to complete for Community Service: |
| |
|
| How did you hear about NCCF? |
|
|
| Why are you interested in volunteering? |
| |
|
| Area(s) interested in volunteering: |
| |
|
References (personal and/or professional) (required)
* Please NO family members |
| Name: |
Phone: |
| Name: |
Phone: |
| |
EMERGENCY CONTACT: |
| Name: |
Phone: |
| |
|
| Volunteer Health Questionnaire / Communicable Disease |
| Have you ever had any of the following diseases or vaccines: |
| Chicken Pox: |
|
| German Measles:(Rubella) |
|
| Measles: (Rubeola) |
|
| Mumps: |
|
| Have you had PPD (TB skin test) in the last 12 months? |
| |
|
| IF YES: |
Date of PPD(Month/Year): |
| |
PPD Results:
|
| IF PPD was Positive: |
| |
Did you get a chest x-ray?
Chest x-rays were:
|
| IF chest x-ray was Positive: |
| |
Did you receive treatment:
|
| |
|
| |
|
| I certify that the above information is correct to the best of my knowledge. (required) |
| Name: |
|
| Date: |
|
| |
|
Click the button below to send the application via email. You can also print and mail the form to the address below:
Alisha Matlock
Director, Volunteer and In-Kind Resources
National Center for Children and Families
6301 Greentree Road
Bethesda, MD 20817-3368
amatlock@nccf-cares.org
(301) 365-4480, ext. 113
|
| |
|
