Application for volunteer service

Last Name First NameĀ  Middle
Address Apt/Lot
City State Zip Code
Home Phone Work Phone Gender
Best Time(s) to reach you by Phone: Email Address
Are you 18 years old of age or older YesNo Birthdate

Availability How often are you interested in volunteering:
2-3 times /weekWeeklyTwice a monthMonthlyOther

Please mark the times you are available to volunteer

Monday MorningAfternoonEvening
Tuesday MorningAfternoonEvening
Wednesday MorningAfternoonEvening
Thursday MorningAfternoonEvening
Friday MorningAfternoonEvening
Saturday MorningAfternoonEvening
Sunday MorningAfternoonEvening


Visiting ResidentsHelp with BingoGardeningSewingAnimals/pet therapyBeautry shop assistantParties, Special EventsSpecial presentation for residentsReading to ResidentsBible Study/religious ServicesMusic (Singing, Play instrumentGift ShopCookingArts & CraftsPlay cards or games

Why Are You Applying to Volunteer? Please indicate why you want to volunteer at ICMCF and what you hope to gain.

Are you currently in school? YesNo
If yes Please list where
What level of school have you completed? ElementaryHigh SchoolCollegePost Graduate

Hobbies/Interest/Special Skills Please check all that apply
GardeningCookingAnimalPet therapyReadingSingingCurrent EventsTravelMoviesSports
Instrument played please list:
Arts & Crafts, Please List:

Employment History
EmployedPart-timeFull-timeSelf EmployedRetired

Please list most recent employer:

Telephone Email
Position Supervisor
Have you ever volunteered or been employed by ICMCF? YesNo
If yes, Indicate PositionĀ  Date

PERSONAL REFERENCES Please list two references other than relatives or employers:

Name Daytime Phone Evening Phone How known How long
Do you have any felony charges pending against you? YesNo
Have you ever been convicted or pled guilty or no contest to a crime? YesNo

If you answered yes to either of the two preceding questions, explain by giving date, nature of the offense and circumstances in an attached, signed statement. Conviction of a crime will not necessarily disqualify an applicant from volunteering.

Are you able to perform the essential volunteer job duties of the volunteer positions for which you are applying with or without reasonable accommodation? YesNo
On entering the captcha and clicking submit button, I will volunteer according to my schedule, be dependable, honor the right's of residents and follow all ICMCF policies and guidelines. I give permission for my employment, school and other associates to be contacted for a reference. I also understand that ICMCF will conduct a criminal background check prior to extending any offer for volunteer position.