Volunteer


Interested in volunteering? Please complete and submit this application.

Title
First Name:
Last Name:
DOB:
In school?
yes no
last grade completed?
Address
City
State
Zip
HomePhone
Bus. Phone
E-mail
Cell
Cell Phone Carrier
Chai Lifeline can send text messages to my cell phone.
References
Name
Phone
Relationship
Name
Phone
Relationship
Emergency Information
First Name
Last Name
Home Phone
Bus. Phone
Relationship
Employment Information
Current Employer
Employer
Job Title
Address
City
State
Zip
Start Date
Volunteer Experience
Organization
Job Title
Address
City
State
Zip
Start Date
End Date
Organization
Job Title
Address
City
State
Zip
Start Date
End Date
Volunteer Interests
Hours Available To Volunteer
Languages Spoken Fluently
Special Skills
Which of the services below would you be willing to volunteer? (choose all that apply)
 
Big Brother/Big Sister Program (spend some quality time with a "little brother or sister")
 
Hospital Respite - Daytime
 
Hospital Respite - Evening
 
Hospital Respite - Night
 
Home Respite - Daytime
 
Tutoring (judaic studies)
 
Translation
 
Transportation assistance (Drive patients and caregivers to hospitals or medical appointments.)
 
Office Work
 
Other (specify Below)
Please note that if you would like to work with patients, you will be required to fill out a medical form.
Comments:
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

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