Peninsula READS - DOC by P2UI42

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									                             Volunteer Information Form

                                                                                            Workshop            ______
                                                                                            VALIT               ______




     The information you provide is for use within the agency & is not shared outside of Peninsula READS

  Month/Year:_______________ Location to volunteer: Newport News or Hampton Library (circle one)

  Name: (First)_____________________(Middle)________________(Last)______________________________

  Name or nickname used: ____________________________________________________________________

  Address: _________________________________________________________________________________

  City:___________________________________________ State:                      VA     Zip Code: ___________________

Is it okay to mail information to your home?          Yes       No   (please circle one)

Phone: Home:____________________________                        Is it okay to call?   Yes    No     (please circle one)

Work:___________________________________                        Is it okay to call?   Yes    No     (please circle one)

Cell:____________________________________                       Is it okay to call?   Yes    No     (please circle one)

E-mail Address: _____________________________________________________________________________

Emergency Contact Name: ___________________________                     Phone:________________________________

How did you hear about Peninsula READS? _______________________________________________________

*(Please provide for granting purposes)
*Gender: (circle) M / F         *Date of Birth: ______________
*Ethnicity:(check) _____ American Native/Alaskan Native         _____Asian       _____ Black/African American
_____ Hispanic/Latino _____ White    _____ Hawaiian/Other Pacific Islander       _____Other

*Employment Status: (please circle one) Full-time       Part-time Student Homemaker Retired*                Other

*If employed:        Occupation: _________________________________________________________________

                     Nature of Business or career field: _______________________________________________

                     Employer: __________________________________________________________________

*If retired, please share your former occupation & employer: __________________________________________

__________________________________________________________________________________________


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                                Volunteer Information Form
*Educational Background: (please check applicable options)

    GED recipient ____________           High School Diploma ______              Some College _______

    Associates Degree _________          Bachelors Degree _________              Graduate Degree _____

    Professional Licensing ____          __      Technical Qualification _____

*I belong to the following social/civic organizations:

    _________________________________________________________________________________________

    _________________________________________________________________________________________

I attend the following church/temple/faith service: (optional) _____________________________________________

I enjoy the following volunteer and leisure time activities:

    _________________________________________________________________________________________

    _________________________________________________________________________________________

Please check the following volunteer opportunities that interest you:

    ___ Basic Literacy Tutor     ___ English as a Second Language Tutor

    ___ Office Volunteer         ___ Computer Lab Volunteer             ___ Basic Math Tutor

    ___ Special Events           ___ Student Recognition/Activities



Availability to volunteer – Please indicate the days and times you would like to volunteer:

    _________________________________________________________________________________________

    _________________________________________________________________________________________

                         Thank you for your interest in volunteering with Peninsula READS!




     Staff Use Only:

     Received by: ___________________________

     Tutor Status: BL ________ ESL ________ Math _______ Other (explain) _______




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