Volunteer Application Form - Junior Personal InformationBirth Date :*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920You must be at least 13 years old to applyName : First Last Address : Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone :Cell Phone :Email Address : Father / Legal Guardian Name : First Last Email Cell Phone :Employer Name :Work Phone :Mother / Legal Guardian Name : First Last Email Cell Phone :Employer Name :Work Phone :Academic BackgroundSchool :City :Grade Level :Grade Point Average :Counselor Name :Languages You Speak :Interests, Hobbies, Or Special Talents :Reason For Volunteering :Other Organizations Where You Volunteered :Commitment Available Start Date : Date Format: MM slash DD slash YYYY Commitment Available End Date : Date Format: MM slash DD slash YYYY Physical and Medical BackgroundGenderMaleFemaleDo you have any physical condition(s) or medical problem(s) that may limit your ability to perform the work of a volunteer :YesNoPlease describe your limitations :Are you currently being treated for any illnesses :YesNoPlease explain :Allergies :YesNoPlease explain :Surgeries :YesNoPlease explain :Back Injuries :YesNoPlease explain :Lifting Limitations :YesNoPlease explain :Have you ever had a TB test before :YesNoWhen :Result :PositiveNegativeHave you had a Chest X-ray in the last 5 years :YesNoWhen :Personal Physician Name : Dr. Prefix First Last Office Phone :Office Address : Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Volunteer AgreementI agree that the above information is correct as of the date it has been completed.* Yes, I agree. Your signature indicates your approval for a reference check. Santa Teresita is not obligated to provide a placement, nor are you obligated to accept the position offered.
