VOLUNTEER CLEARINGHOUSE APPLICATION
OFFICE OF COMMUNITY SERVICE-LEARNING
A DIVISION OF STUDENT AFFAIRS AT THE UNIVERSITY OF SOUTHERN MISSISSIPPI
USM Box 10031, Hattiesburg, Mississippi 39406-5067 (601) 266-5074
Please take a moment to complete the following information. The more information we have about you, the
easier it will be to find a placement you would enjoy!
E-MAIL CLASSIFICATION (Students Only) MAJOR (Students only)
LOCAL ADDRESS CITY ZIP
LOCAL SCHOOL PHONE WORK PHONE BEST TIME
TRANSPORTATION AND LIMITATIONS
Will you be able to provide your own transportation? Yes No
EXPERIENCE Please indicate any experience that may be useful in a volunteer placement. Keep in mind that you are not
expected to be an expert in these areas. Some placements will require working knowledge only!
Previous or Current Volunteer Work______________
Club, Church, or Organizational Affiliations________________
Hobbies, Leisure-time Activities, or Special Interests_______________
Special Skills and Training: Please circle those items that you have skills or training in, and indicate your level of expertise.
expert average no skills
Foreign Language 1 2 3 4 5 (What language? )
Musical Instrument 1 2 3 4 5 (What instrument? )
Computer Skills 1 2 3 4 5 (What skills? )
Typing 1 2 3 4 5 (WPM )
Singing Ability 1 2 3 4 5
Sign Language 1 2 3 4 5
Photography 1 2 3 4 5
Grant Writing 1 2 3 4 5
Newsletters 1 2 3 4 5
Other 1 2 3 4 5 __________________________
CPR CERTIFIED BY EXPIRATION
FIRST AID CERTIFIED BY EXPIRATION
LIFEGUARDING CERTIFIED BY EXPIRATION
DISASTER RELIEF CERTIFIED BY EXPIRATION
Revised July 2002
1. Why do you want to volunteer?
2. When would you like to start?
3. When are you available to volunteer (please circle)? Mornings Afternoons Evenings Weekends Holidays
4. What type of commitment are you willing to make?
Long-term (Ongoing) Hours per week Duration
Short-term (Specific project for a few weeks/days) Hours per week Duration
On call/Special events
5. May we release your name, phone number, and address to agencies interested in contacting you with volunteer opportunities ?
YES NO PLEASE INITIAL.
Indicate the types of things that are interesting to you. Circle your top three choices for each listing.
Age Level Special Populations Volunteer Activities
Types of Agencies
Infant AIDS Arts and Crafts Driver/Errands
Preschool Animals Friendly Visits Fund-raising
Elementary The Arts (Dance, Theatre) Bulk Mailings Gardening/Landscaping
Junior High At-Risk Youth Child Care Job Training/Rehab
High School Crime Prevention Classroom Aide Mentoring/Tutoring
Young adult Developmentally Disabled Clerical Tasks Physical Labor
Adult Drug Prevention/Education Community Awareness/Education Recreational Activities
Elderly Domestic Abuse Computer Assistance Shelter Work
Education Construction/Home Repair Special Education
Elderly Crisis Hot Line
Emotionally Disturbed Desktop Publishing
Environment Disaster Relief
FOR OFFICE USE ONLY
Revised July 2002