Interested in volunteering? Please complete and submit this application.

Title Mr. Mrs. Ms. Miss Dr. First Name: Last Name: Address City State Please select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside USA Zip Home Phone Bus. Phone Cell E-mail AGE RANGE: Except for volunteers under 18, who are required to respond, this question is not mandatory. The information is requested for statistical purposes only. Select One under 18 19-25 26-32 33-39 40-46 47-53 54-60 61 & above Employment Information Occupation Years Employed Current Employer     Employment Experience Current: Job Title   Start Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998     Past: Job Title   Start Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 End Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 In school? yes no last grade completed? Degree Volunteer Experience Current Organization   Start Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 End Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 Past Organization Start Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 End Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998   Organization Start Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 End Date January February March April May June July August September October November December 201220112010200920082007200620052004200320022001200019991998 Hours Available To Volunteer Languages Spoken Fluently Special Skills Have a car? yes no How far are you willing to drive? Check 4 areas in which you would like to be involved:   Driving Meals to Hospitals/Clients Homes   Visiting Families in Hospitals   Clerical Work   Big Brother/Big Sister Program (weekly commitment required)   Home Respite - Daytime   Family Support Program (weekly commitment required)   Event Planning   Event Staffing References Name Phone Relationship Name Phone Relationship In Case of Emergency Notify: First Name Last Name Home Phone Cell Phone Relationship How did you hear about Chai Lifeline?   What volunteer or experiences have helped you to prepare for working with Chai Lifeline families? Tell us about an event or experience that has had a significant impact on your life. What qualities would you bring to Chai Lifeline that would benefit our families? What are your expectations of being a CLL volunteer? Have you ever been convicted of any crime, including sex-related or child abuse related offenses in any state or country? Yes No If you have a professional license, have you ever been required to surrender your license by the licensing board or professional ethics body? Yes No N/A Have you ever been found guilty of violation of professional ethics codes, professional misconduct, or unprofessional conduct, in any state or country? Yes No