Volunteer

Title:
First Name:		Last Name:
Address:		City:
State:		Zip:
Phone:		Cell:
Work Phone:
DOB:		E-mail:
Are you currently employed? yes no
Name of Employer:		Years Employed:
Address:
City:		State:
Zip:
Are you currently a student? yes no
Name of School:		Last Grade Completed?
Degree or Expected Date of Graduation
References
Name:		Phone:
Relationship:
Name:		Phone:
Relationship:
Emergency Information
First Name:		Last Name:
Home Phone:		Bus. Phone:
Relationship
Volunteer Experience
Organization:		Job Title:
Address:
City:		State:
Zip:
Start Date:
End Date:

Organization:		Job Title:
Address:
City:		State:
Zip:
Start Date:
End Date:
I-shine Operates Monday & Wednesday 4-6:30PM
I am available to volunteer Monday Wednesday Both Monday & Wednesday
Languages Spoken Fluently

Special Skills Teaching (list subjects), Arts & Crafts, Musical Instruments, Sports, Other Talents

How did you hear about Chai Lifeline?

Comments:

Have you ever been convicted of any crime, including sex-related or child abuse related offenses in any state or country? Yes No
I have truthfully completed this application. I will honor the time commitment required for my volunteer assignment and will adhere to all policies and procedures outlined in any materials provided by Chai Lifeline. Agreement of confidentiality As an i-Shine volunteer, I understand that in the course of my work with this program, I might learn privileged and confidential information about the children and their families, including, but not limited to medical conditions and treatment, finances, living arrangements, employment, and/or relationships among family members. I understand that all such information must be treated as confidential. I agree to disclose any information learned about patients and their family members only to one of the adult coordinators of the program. I understand unauthorized disclosures are considered grounds for immediate termination of volunteer status.
Signature:

Click here to download the volunteer application (pdf)