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Volunteer Interest Form

"*" indicates required fields

Title

First Name*

Last Name*

Cell Phone Number*

Home Phone Number

Email Address*

I Am Inquiring About:

Address Line 1

Address Line 2

City

State

Zip Code

Are you between 13 and 17 years of age?*

Yes

No

Are you under 13 years of age?*

Yes

No

Status

I am Employed

I am Retired

I am a Student

Where are You Employed?

Where did You Retire From?

How Many Volunteer Hours Do You Need?

Date to Complete Hours by?

MM slash DD slash YYYY

What is Your Education Level?

What Special Skills or Interests do You Have?*

Where do You have Previous Volunteer Experience?*

Why Are You Interested in Volunteering?*

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

General Availability

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

Morning

Afternoon

Evening

Sunday

Morning

Afternoon

Evening

Monday

Morning

Afternoon

Evening

Tuesday

Morning

Afternoon

Evening

Wendesday

Morning

Afternoon

Evening

Thursday

Morning

Afternoon

Evening

Friday

Morning

Afternoon

Evening

Saturday

Morning

Afternoon

Evening

Have you ever pled guilty to, been convicted of, been released without imposition of sentence, or received pretrial diversion for any crime? (Felony or Misdemeanor)**

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

Local Emergency Contact

First Name*

Last Name*

Relationship*

Phone Number*

Family Doctor*

Doctor's Phone Number*

Preferred Hospital*

Electronic Signature*

Date*

MM slash DD slash YYYY

Time*

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(937) 433-2110
information@graceworks.org

Address

6430 Inner Mission Way
Dayton, OH 45459

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