Application for Volunteer Service

  Connellsville Area Community Ministries
  110 West Crawford Ave, Connellsville PA 15425
  724-626-1120

Our organization encourages the participation of volunteers who support our mission. If you agree with our mission and are willing to be trained in our procedures, we encourage you to complete this application.
Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, Veteran status, or the presence of a non-job-related medical condition or handicap.

Please print all information

Name: __________________________________________________________ [   ] Female [   ] Male

Home Phone: _________________ Cell Phone: _________________ Birth Date (optional): ___________

Address: _____________________________City: ______________ State: ___________ Zip:__________

Emergency Contact:

Name: __________________________________________ Relationship: _________________________

Home Phone: ____________________ Cell Phone: ____________________

Availability: (Circle all that apply)   Monday       Tuesday     Wednesday    Thursday      Saturday

Do you have any physical limitations?    No     Yes

       If yes, please describe____________________________________________________________

Have you been convicted of a felony in the last 7 years?   No   Yes

      If yes, please describe____________________________________________________________

Do you have any previous volunteer experience?    No   Yes

      If yes, please describe____________________________________________________________

References:

Name _______________________________________ Phone _________________________________

Name _______________________________________ Phone _________________________________

Name _______________________________________ Phone _________________________________

I certify that all information submitted by me on this application is true and complete. I understand that if any false information, omissions or misrepresentation are discovered my active volunteer status may be terminated at any time. I also agree to adhere to the policies and regulations of CACM and that my volunteer status can be terminated with or without cause, and with or without notice, at any time by CACM.

 

Signature _______________________________________ Date ________________________