Print this form, fill it out and take it to York-Poqouson Red Cross.
PLEASE PRINT INFORMATION
Today's Date: ____________
(Circle one) MISS MRS. MS. MR. REV.
___________________________________________________________________________
| Last Name | First Name | M.I. | Nickname |
Date of Birth (Month/Day/Year) _________
___________________________________________________________________________
| Home Address | City | State | Zip |
Home Phone ______________________________ Business Phone _____________________
Employer _________________________________ Title ______________________________
Emergency Contact:
Name: _______________________ Phone (Day) ___________ (Night) ___________________
Availability
Days Available ___________________ Hour(s) Available _______________________________
Are you willing to serve in times of natural disasters?
(Example: Hurricane, Flooding, Fires, Tornado, etc.) ___Yes ___No
Check one: ______ Local disaster _____ National Disaster
Academic Education:
Last grade completed (1-19) _____
Full-time student ______ Part-time student ______
The following information is used only to determine the diversity of Red Cross volunteers.
Are you disabled? ____ Yes ___ No
If Yes, please explain: _______________________________________________________
U.S. citizen? ____ Yes ____ No
Veteran:
___ Disabled Veteran
___ Vietnam Veteran
___ Veteran Any War
Ethnicity:
___ American Indian/Native Alaskan
___ Asian Pacific Islander
___ Black
___ Hispanic
___ White
___ Other
Have you ever worked for the American Red Cross? ___ Yes ___ No
Please indicate the type of volunteer work you are interested in:
|
Administration ___ Filing ___ Telephones ___ Typing & Data Entry
Armed Forces ___ Emergency Communications ___ Intake & Casework
Blood Services ___ Bloodmobiles ___ Sign-in (Fixed sites) ___ Volunteer scheduling |
Disaster Service ___ Local Disaster Response ___ National Disaster Response
Health & Safety Services ___ Teaching/Training ___ Data Entry
Fundraising ___ Bingo ___ Special Project ___ Special Events ___ Bulk Mail |
I understand that American Red Cross volunteers do not accept pay for services to the public. I hereby grant the Red Cross Office of Volunteers permission to use discretion regarding disclosure or use of this or any other information about Red Cross services. I recognize the right of the Red Cross to terminate the service of any volunteer whose conduct in any way reflects negatively upon the American Red Cross. I agree to abide by the volunteer policies and procedures of the Chapter.
_________________________________________________________________________________
| Volunteer's Signature | Date |
Date of Interview: ____/___/___
Interviewer's comments: _________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
If you need more information regarding the volunteer opportunities we offer or have other questions feel free to call 898-3090 or contact us.