SIXTH AVENUE
PSYCHIATRIC REHABILITATION PARTNERS, INC.
VOLUNTEER REGISTRATION FORM
Name
____________________________________________________ Date
_______________________________________
Address_______________________________________________________________________________________________
______________________________________________________________________________________________________
Home phone number
________________________ Work number _
___________________________________
Person to be contacted in an
Emergency Name
Name
______________________________________________ Telephone
_______________________________________
Available for volunteering:
Day (s) of the week ___________________________________ Hours
___________________________________________
Are you presently employed?
____________________________ Do you
have transportation? _________________________
Are you under 18 years of age?
_________ If
yes, Parent or Guardian Signature __________________________________
Any information
that you would like for us to be aware of? (Problems lifting, allergies, sight or Hearing impairment) _________
______________________________________________________________________________________________________
Special skills, training,
educational background, interests, and hobbies:
_____________________________________________
What area of
Sixth Avenue Psychiatric Rehabilitation Partners, Inc. are you
interested in volunteering? ____________________
_______________________________________________________________________________________________________
Have you been a volunteer for
another agency, scouts, church?
____________________________________________________
List three references that are
not family members including telephone number or address:
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________