Volunteer Application Form

Episcopal Church Home • Brentland Woods
River Edge Manor • Seabury Woods

Name:

Address:

City:

Zip:

Home Phone:

Business Phone:

Birth Month/Day:

Email Address:

Volunteer Experience:

Employment Experience:

Special Skills or Training:

Volunteer Job Preferred (See Opportunities Sheet):

Availability & Frequency:

Weekly

Monthly

On Call

Fill In Times Below:

Hours	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Afternoon
Evening

Are you away for any extended time during the year?

If so, When?

Emergency Contact #1 Information
Name:		Home Phone:
Address:		Business Phone:
Relationships:

References (Two people, not relatives, we can contact that can vouch for your character, reputation, and work record).
Name:		Home Phone:
Address:		Business Phone:


Name:		Home Phone:
Address:		Business Phone:

OPTIONAL Church:

Clergy:

Have you ever been convicted of a crime (other than traffic violation)?:

If so, please explain:

Do you have a final finding of patient or resident abuse?

Were you ever removed from any type of employment?

Note: Prior criminal conviction is not necessarily a bar to volunteering.

I authorize Episcopal SeniorLife Communities to verify the accuracy of information provided on this application and to obtain reference information. I hereby release Episcopal SeniorLife Communities, and party supplying references, from any liability for a placement decision based on such information.

Please sign this application by typing your name below.

Signature:

Date:

Referred By:

Click here to submit this application.