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Graceworks Lutheran Services Volunteer Application

* Denotes Required Field.

Title:
First Name:*
Last Name:*

Phone:
Home:*
Work:

Address:*
City:*
State:* Zip:*
Email:

Date of Birth:* Age:*

Male Female

Single Married

Employed: Where:

Retired: From:

Church Affiliation:

Student hrs. needed: Date to complete:

Education Level:
Elem. MS HS Voc Tech Jr. College
Some College Assoc. Degree BA/BS
MS/MA/MBA PhD

Special Skills or Interest:*

Previous Volunteer Work (Type of work):*

Where:

Why are you interested in volunteering?*

Please list the type(s) of volunteer work you are interested in:*

How did you hear about the volunteer service opportunities at Graceworks Lutheran Services?

Days and times you are available to work:* (Please check the appropriate boxes)

Time	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
A.M.
P.M.
Eve.

Please list three references you have known for one year or more:* (non-family)

	Name:	Address:	Phone Number:
Reference 1.
Reference 2.
Reference 3.

Have you ever been convicted of a felony, theft or abuse?*
Yes No

Are you performing work as part of a diversion program?*
Yes No

Will you agree to a voluntary background check?*
Yes No

Do you have any allergies, medical conditions, or physical limitations that Graceworks Lutheran Services should be aware of in the event of an emergency?*
Yes No
If "Yes", explain:

Emergency Contact:*
Name:
Relationship:

Preferred Hospital: