Volunteer Application Form - Junior Personal InformationBirth Date :*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920You 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 : MM slash DD slash YYYY Commitment Available End Date : MM slash DD slash YYYY Physical and Medical BackgroundGender Male Female Do you have any physical condition(s) or medical problem(s) that may limit your ability to perform the work of a volunteer : Yes No Please describe your limitations : Are you currently being treated for any illnesses : Yes No Please explain : Allergies : Yes No Please explain : Surgeries : Yes No Please explain : Back Injuries : Yes No Please explain : Lifting Limitations : Yes No Please explain : Have you ever had a TB test before : Yes No When : Result : Positive Negative Have you had a Chest X-ray in the last 5 years : Yes No When : 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.
