1.       Do you speak any language other than English fluently?  (Please List)_______________________________

2.       Education level attained

Degree______________________ School:________________________ Major:_____________________

Degree______________________ School:________________________ Major:_____________________

Degree______________________ School:________________________ Major:_____________________

3.       What are some other skills and experience you feel would be helpful at the Albany Damien Center?

4.       My reasons for wanting to become a volunteer at the Albany Damien Center are:

5.       Please give a description of your current employment, affiliations with area civic organizations, and any experience with working with persons living with HIV/AIDS. (Use back page if necessary.)

6.       Please list volunteer activities with dates of service:

Area(s) of Interest:

Availability:  What times/days you would be available to volunteer between 9 AM & 9 PM?

I expect to devote approximately  _________  volunteer hours per month to Albany Damien Center

References: Please include one professional and one personal reference.

1. Name: _______________________________ Phone:________________________________

Address: (no PO Boxes):___________________________________________________________

Relationship______________________________ Best time to call___________________________

2. Name: __________________________________ Phone:__________________________________

Address: (no PO Boxes)____________________________________________________________

Relationship______________________________ Best time to call___________________________

Have you ever been arrested for an offense resulting in a conviction? q Yes    q     No

If yes, please state offense:__________________________________________________________

Conviction date:______________ Court:______________ Court Address:_____________________

Court docket #:______________ Date:______________ Disposition: ________________________

Have you been arrested for an offense where the disposition of said arrest is currently pending? qYes q  No

If yes please state offense:___________________________________________________________

Date of arrest:_______ Offense:_________________ Court & Address:_______________________

Court docket number_____________ Status of arrest currently pending:________________________

Emergency Contact – Please list who we should contact in the event of an emergency

1. Name: _______________________ Phone:_____________________ Relationship_______________

2. Name: _______________________ Phone:_____________________ Relationship_______________

Please include a copy of your drivers license or other valid picture ID with this application.

Agreement:

 I attest that all the information given in this application is true.  I understand the importance of volunteerism and the work that I will do with the Albany Damien Center.  I will make every effort to notify the Albany Damien Center of change(s) of address/contact information, availability, or any other information that I have provided on this form.  I will allow my phone number and e-mail information to be shared with other Albany Damien Center Volunteers/Staff.  Upon acceptance as an Albany Damien Center volunteer, I agree to hold Albany Damien Center harmless for any and all situations arising from Albany Damien Center business.

Signature__________________________________________

Printed Name_______________________________________

Date_____________________________________________

Staff Reviewed:

Review Date:

Comments:

Albany Damien Center Volunteer Application - Rev. 2/04