Your Name (required)

Address:

City:

State:

CT - ConnecticutMA - Massachusetts

Zipcode:

Place of Employment:

Job Title:

Work Phone:

Home Phone:

E-Mail Address:

Date of Birth:

Sex:
MaleFemale

Race:
American IndianAsianBlackLatinoWhiteOther

Education:
Under 12 years of High SchoolSome CollegeUndergraduateGraduate Degree

Employment status:
EmployedRetiredUnemployed

Positions interested in:
TutorComputer Lab AssistantSpecial Events Volunteer

I am available to volunteer:
MorningsAfternoonsEveningsAs needed

Time commitment:
MorningsAfternoonsEveningsAs needed

How did you hear of us ?:

In addition to English, what language(s) do you know ?:

Have you even been convicted of a crime other than a misdemeanor ?:
 Yes No

If Yes, please list date and charge:

Do you have any physical, mental or medical disabilities that might limit your
ability to perform your duties with Literacy Volunteers?
 Yes No

If yes, please describe:

Why are you interested in working with Literacy Volunteers?
If applicable, please comment on prior volunteer experience.

Please list any special skills/abilities or special interests
that you would be willing to volunteer to Literacy Volunteers
(e.g. graphic design, creative writing, party/special event planning,
computer skills, media/community contacts.)

Personal References -
Please provide at least one work/volunteer reference if possible:

Name: Relationship: Phone:

Name: Relationship: Phone:

Name: Relationship: Phone:

I understand that the information on this application is subject to verification. I agree that if accepted as a volunteer, I will abide by the volunteer regulations as outlined by Literacy Volunteers of Greater Hartford.

Agreed to by:

Date: