Volunteer Application Form

This form may be filled out online or printed and mailed in.

Name:			Date of Birth:
Address:			SS #:
City:		State:	Zip:
Phone:	(Home):		(Office):
E-Mail:
Emergency Contact:			Phone:

I. Skills and Interests

1. Education background:
2. Current occupation:
3. Hobbies, skills, interests:
4. Previous volunteer experience:

II. Preferences in Volunteering

1. Is there a particular type of volunteer work in which you are interested?

2. Do you have any special skills you could offer to our residence
(musical ability, computer knowledge, yoga instructor, etc.)?

3. Are there any groups with which you would not feel comfortable working?

III. Availability

1. At what times are you intereested in volunteering?

Am Flexible	Prefer Weekdays	Prefer Evenings
Prefer Weekends	Prefer Days	Other

2. Do you have access to an automobile you can use for volunteer work? Yes No

IV. Background Verification

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

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

3. Has your driver's license ever been suspended or revoked in any state? Yes No

4. Do you use illegal drugs? Yes No

5. Do you have any physical limitations or are you under any course of treatment which might limit your ability to perform certain types of work? Yes No

6. Please list two non-family references whom we might contact:
a. Phone:
b. Phone:

7. How did you hear about us?

Saw job description	Saw advertisement	Volunteer center	Website
Friend	Agency/school	From client of agency

Verification

A copy of this application can be sent to you (HTML format only)
Would you like a copy of this application sent to your e-mail address? Yes No

To make sure you are not a spamming robot,
please enter "Hilltop" in the box below:

Hilltop House is a nonprofit corporation which owns a 124-unit apartment building. It is an equal opportunity facility that provides housing to low-income individuals 62 years of age and older through the Department of Housing and Urban Development's 202 Program. Residency is open to all qualified person without regard to race, color, creed, national origin, handicap status, religion, familial status, political persuasion, sex, or sexual preference.