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Volunteer Application Form

First Name: *

Last Name: *

Address:

Apt#:

City:

Postal Code:

Home Phone:

Business/Cell Phone:

Email Address: *

Other languages spoken fluently:

Other (please indicate language):

How did you learn about volunteer opportunities with our agency?

Why are you interested in volunteering with Pathstone Mental Health?

What skills do you feel you can contribute as a Volunteer? (academic, experience, etc.)

Outline your previous volunteer experience:

Some volunteer positions require building relationships with clients, which can be a slow process. Are you able to commit to volunteering for:

6 to 12 months

12+ months

Do you have access to a vehicle?

Yes

Do you have at least $2 million liability insurance for your vehicle?

Yes

What do you enjoy in your leisure time? (Hiking, recreational activities, biking, art, musical instruments, gardening etc)

References: Provide 2 references which are current, professional, and have known you for 2 years or more. Provide 1 reference which is a Family member.

Reference 1

Name

Address

Phone

Relationship

Reference 2

Name

Address

Phone

Relationship

Reference 3

Name

Address

Phone

Relationship