Volunteer Application Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Employment Status:*EmployedUnemployedRetiredPlace of Employment (Previous if Retired):* Job Title: Cell Phone:*Home Phone:Email* Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920*Must be 18 or older to volunteer.Sex:MaleFemaleRace Asian Black Hispanic/Latino Native American White Other Education:*Less Than 12 yearsHigh School Diploma (or equivalent)Some CollegeUndergraduateGraduate DegreeDoctorate Degree*A minimum of a high school diploma or equivalent is required for the tutor and lab volunteer positions.Positions Interested In:* Tutor Childcare (Tuesday/Thursday AM) Days Available:* Monday Tuesday Wednesday Thursday Friday Time Commitment:* Mornings Afternoons Evenings *Note, most opportunities are available in the mornings or evenings. How did you hear about us? In addition to English, what language(s) do you know? Have you ever been convicted of a crime other than a misdemeanor? Yes No If Yes, please list date and charge: Would you like to disclose any physical, mental, or medical challenges/disabilities? If so, please describe any accommodations you would require in order to perform your duties with Literacy Volunteers: 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.)Emergency Contact - Please provide at least one emergency contact if possible:Name: Relationship: Phone: Personal References - Please provide at least one work/volunteer reference if possible: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* MM slash DD slash YYYY
