Well•Spring

Position(s) Applied For

*

Referral Source

Newspaper Volunteer Center of Greensboro Employee Relative Resident Web Site Other

Name of Source
(if applicable)

First Name

    M      Last Name  *

Address

City

    State      Zip  *

Phone #

*    Mobile/Other #

Email

*

Birthday

   Age

Yes    No

May we call you at work? *

If yes, work number and best time to call

Emergency Contact

Relation

    Phone  *

Yes    No

Have you ever been convicted of any criminal offense other than a minor traffic violation? *

Yes    No

Are you applying to volunteer as a court appointed volunteer? *

Special interests or talents

Provide at least one reference who is not a relative.

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comment section at the end of the application.

1. Employment Data

Name

Phone #

Yes   No   Later

May we contact for reference?

Yes    No

Do you volunteer currently?

If yes, where?

Yes    No

Are you seeking to volunteer to complete a required number of hours for school credit?

If yes, list school, class, number of required volunteer hours and goal of volunteer experience

Yes    No

Do you have experience working or volunteering in long-term care?

If yes, describe.

Days most convenient to volunteer?
(check all that apply)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Days most convenient to volunteer?
(check all that apply)

Morning
Afternoon
Evening

Frequency of voluteering?
(check all that apply)

Daily
Weekly
Bi-weekly
Monthly
Weekends only

If explanation for time available is needed, please describe.

Date available to begin volunteering?

*

Yes    No

Do you have any limitations we should be aware of?

If yes, describe.

Comments

List any other explanation you would like to give concerning your desire to volunteer at Well-Spring.