Volunteer Application Form Personal InformationName : Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Gender : Female Male Birth Date :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address : 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 : Yes No Where is your work : Current Position : Work hours per week : Employer : Supervisor Name : Supervisor Phone Number :Hire Date : Month Day Year Last Date worked : Month Day Year Previous Employer : Position : Education InformationAre you currently going to school : Yes No Which School : Last School Year Completed : Degree / Certification : Volunteer ExperiencePrevious Volunteer Experience : Yes No Where : Why do you want to volunteer :How did you hear about Santa Teresita :Commitment Available Start Date : MM slash DD slash YYYY Commitment Available End Date : MM slash DD slash YYYY Physical and Medical InformationAny physical condition or medical problem that may pose limitations for you: Yes No Please describe your limitations: Are you being treated for any illnesses currently : Yes No Please explain : Do you have any allergies? Yes No Please list allergies : 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 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.