Volunteer Application Form Personal InformationName : Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Gender :FemaleMaleBirth Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address : 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 :Work Phone :Email Address : Employment InformationAre you presently employed :YesNoWhere is your work :Current Position :Work hours per week :Employer :Supervisor Name :Supervisor Phone Number :Hire Date : MM DD YYYY Last Date worked : MM DD YYYY Previous Employer :Position :Education InformationAre you currently going to school :YesNoWhich School :Last School Year Completed :Degree / Certification :Volunteer ExperiencePrevious Volunteer Experience :YesNoWhere :Why do you want to volunteer :How did you hear about Santa Teresita :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 InformationAny physical condition or medical problem that may pose limitations for you:YesNoPlease describe your limitations:Are you being treated for any illnesses currently :YesNoPlease explain :Do you have any allergies?YesNoPlease list allergies :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 Address : Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office Phone :Emergency ContactName : First Last Relationship :Home Phone :Work / Cell Phone :ReferencesPlease provide 2 references, with at least 1 professional reference.Name : First Last Replationship :Company Name ( if applicable ) :Phone :Address : Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name : First Last Replationship :Company Name ( if applicable ) :Phone :Address : Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Volunteer AgreementPlease check to agree that the above information is correct as of the date it has been completed.* Yes, I agree. Your agreement 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.