First Name Last Name
Home Address
City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip
Evening Phone Email
Birthday Month 01 02 03 04 05 06 07 08 09 10 11 12 / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Employer Job Title
Work Address
Daytime Phone Work Email
Preferred Mailing AddressHome Work
Preferred Email AddressPersonal Work
Which volunteer positions are you interested in?
Fund Development Committee Member (E.g., Fundraisers, Grants, etc.) Program/Finance Committee Member (E.g., Program development, Audit & budget planning, Financial statements, etc.) Marketing/PR Committee Member (E.g., Marketing & PR planning, etc.)
Group Facilitator Casemanager/Counselor Children's Advocate/Aide
Clerical/Technical support Other
Who referred you to this agency?
Is your company willing to support your involvement with Serenity Services? Yes No, I'm a community volunteer
How long can you commit to Serenity Services? Per Event 1 - 6 Months 6 - 12 months >1 Year
Have you ever been convicted of or plead no contest to a crime of physical or sexual abuse on another person? Yes No
Please list two references and their daytime phone numbers
Name Phone
I affirm that the information provided is accurate to the best of my knowledge
