PART I - GENERAL INFORMATION.

               Last:  
              First:  
            Address:  
               City:  
              State:  
                Zip:  
             E-mail:  
          Day Phone:  
      Evening Phone:  
    Employer/School:  
  Emergency contact:  
    Emergency Phone:  

PART II - BACKGROUND INFORMATION. Note that all information will be treated as confidential and may be verified.

Do you use illegal drugs?....................................Yes  No

Have you ever been convicted of a criminal offense?..........Yes  No

Have you ever been criminally charged with neglect,
abuse or assault?............................................Yes  No

Has your driver's license ever been suspended or revoked?....Yes  No

Have you ever been adjudged liable for civil penalties or
damages involving sexual or physical abuse?..................Yes  No

If you answered YES to any of the above, please explain:

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PART III - REFERENCE INFORMATION - Please provide two references. IF YOU ARE UNDER 18, Please provide at least one school or institution reference..

               Name:  
             Street:  
     City/State/Zip:  
         Home Phone:  
         Work Phone:  

               Name:  
             Street:  
     City/State/Zip:  
         Home Phone:  
         Work Phone:  
     

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PART IV - VERIFICATION CODE - This step prevents unauthorized use of this form

Please enter the code as it appears above: 

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Please be certain that all requested information has been supplied. If any information is missing, this application will not be processed.

By submitting this form, you state that you have read both the volunteer code of conduct and the volunteer agreement and agree to abide by the terms within.