Volunteer Intake Form

Personal Information

First Name *

Last Name *

Date of birth *

Phone Number *

Email Address *

Address

Street Address

City

State

Postal code

Do you have any disabilities or medical conditions that we should be aware of in order to provide you with the best support?

Yes

If yes, describe:

Emergency Contact

Name:

Phone Number:

Availability

Days Available (check all that apply):

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Available Time *

Morning

Afternoon

Evening

What date are you interested in volunteering with us?

Location or Program

Are you available and willing to participate in a 10–15 minute interview prior to your volunteer day?

Yes

Volunteer Goals and Interests

What are your goals for this Volunteer? *

What Area in our organization interest you most ( Check All that Apply) *

Social Services/ Case Managment
Out Reach / Community engagement
Administration / Office Support
Marketing / Communications
Event Planning / Fundraising
Housing Support Services
Mental Health Services
Other
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Skills and Experience

Do you have Prior Volunteer Or Work Experience ? *

Yes

If Yes, Please Describe Briefly

Languages Spoken

Relevant Skills or Certifications (e.g., CPR, Microsoft Office, Counseling):

Background Information

Have you ever been Convicted of a felony or Misdemeanor? *

Yes

If yes, Please Explain below

Are you willing to submit to a background check if required? *

Yes

Reference

Name

Number

Signature and Acknowledgment

I certify that the information provided is true and complete to the best of my knowledge. I

understand that submission of this form does not guarantee internship placement and that all

placements depend on availability and organizational needs.

Signature

Clear