Name____________________________________________Social Security #_____________________
Home Phone (_____)_______________ Message Phone (_____)__________________
Address____________________________________________________________________________
________________________________City__________________State________ZIP______________
Are you under 18 years of age? _________YES _________NO
Do you have special requirements or medical conditions that the City should be aware of while you are a volunteer? ______YES _______NO
If yes, describe______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Work/Volunteer Experience__________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
What kind of volunteer opportunities are you looking for?_________________________________
__________________________________________________________________________________
__________________________________________________________________________________
List any special interests, skills, knowledge, etc: ___________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Availability:
I will be able to start volunteering (date):__________________for approx._____weeks/months
Days preferred____________________________________________________________________
Hours preferred___________________________________________________________________
Can you work: ______Evenings ______Weekends _______Holidays________Summers
Can you work: _____Daily ________Weekly ________Monthly ________Other
Emergency Contact_________________________________________________________________
Relationship_______________________________________ Phone (______)__________________
Please list two references and their relationships to you (friend, employer, etc.):
Name_____________________________________________________________________________
Address___________________________________________________________________________
City/State/ZIP_____________________________________________Phone (_____)_____________
Relationship__________________________________
Name_____________________________________________________________________________
Address___________________________________________________________________________
City/State/ZIP_____________________________________________Phone (_____)_____________
Relationship__________________________________
____________________________________________________________ ____________________
Volunteer Signature......................................................................................... Date
Print this page out and return to:
Office of Community Services,
City of Burien, 415 SW 150th Street, Burien, WA 98166-1973
Last updated 02/04/06
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