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    Adult Volunteer (Samaritan) Application Form  

    Please complete this form carefully and press the "Submit" button. We will send you confirmation of your application by mail as soon as possible. Thank you! 

    Today's Date:  

    Personal Information  

    First Name:   Middle Initial       Last Name:  
    Date of Birth       
    Email Address:    

    Home Address

    Address:    
    City:         State:   Zip Code:  
    Phone:   () -      

    Work Address

    Company:    
    Address:      
    City:         State:   Zip Code:  
    Phone: () -      

    Experience 

    Education or Special Training  

       

    Volunteer Experience 

       

       

     Work Experience  

       

    Have you ever been convicted of, or pleaded guilty to, a crime which includes felony or misdemeanor at any time after you turned 16 years of age? 

    If yes, please describe in detail. (Note: You do not need to disclose sealed or expunged criminal records.A criminal conviction is not an automatic bar to volunteering. 

     

    Emergency Contact 

    Relationship:  

       
    Address:       
    City:   State:       Zip Code: 
    Phone: () -      

    Personal References (not family members) 

    Name:      
    Address:      
    City:   State:   Zip Code:  
    Phone: () -      
         
    Name:      
    Address:      
    City:   State:   Zip Code:  
    Phone: () -      

    Personal Physician

    Name:  
    Phone: () -  

    Service Preferences

    Areas of Service Preferred 

     

    Preferred Days: First choice: Second Choice:  

    Preferred Hours:   

    Are you available on the weekends?   

    Can you be called to substitute? 

    Comments