APPLICATION FOR VOLUNTEER POSITION

COUNCIL ON AGING, INC., serving St. Clair County

600 Grand River, Port Huron, MI  48060,  (810) 987-8811

INSTRUCTIONS:  Answer all questions.  Questions may be position related or required by state or federal law. 

        It depends upon the type of position for which you are applying.  Your answers will not be       

        considered unless the information is related to the position for which you are applying.

_________________________________________________________Today’s Date:_____________________

 

Volunteer Position(s) Applying For:____________________________________________________________

Last                                                                  First                                             Middle

Name:_______________________________Name:_____________________Name:______________________

 

Street Address with Apt. Number:______________________________________________________________

 

City/State/Zip Code:_________________________________________________________________________

Phone                                                   Social                                                                Date

Number:_______________________Security Number:______________________of Birth:_____/_____/_____

 

Driver’s License Number:___________________________________State Issued In:_____________________

Do you have a Commercial Driver’s License? ƒ Yes   ƒ No     Do you have a Chauffeur’s License? ƒYes   ƒ No

Do you have transportation?  ƒ Yes   ƒ My own car   ƒ Someone will transport me    ƒ No     ƒ I need a ride

 I am applying to do volunteer work from my home:  ƒ Yes     ƒ No 

(A yes answer to either of the two following questions does not automatically disqualify you.)

Have you ever been convicted of a crime other than a minor traffic violation?   ƒ Yes     ƒ No

   If yes, please explain: ______________________________________________________________________

Are there felony charges pending against you?   ƒ Yes    ƒ No

  If yes, please explain:_______________________________________________________________________

Have you ever been employed by the Council on Aging?   ƒ Yes    ƒ No

  If yes:  Dates worked: ___________________________ Department/Position: _________________________

 

Interests/Hobbies/Special Skills: _______________________________________________________________

__________________________________________________________________________________________

Organizations Affiliated With: ________________________________________________________________

__________________________________________________________________________________________

Please list any other training, apprenticeships, military or work experiences that relate to your volunteering: ___

__________________________________________________________________________________________

Text Box: Previous Volunteer Experience: (Attach additional sheets if needed.) Organization: ________________________________________ Position: ____________________________ Person with whom you worked: ________________________ Duties: _______________________________ ************************************ Organization: ________________________________________ Position: ____________________________ Person with whom you worked: ________________________ Duties: _______________________________  

 

 

 

 

 

 

 


EMPLOYMENT HISTORY:

Most Recent Employer:

Company Name: ___________________________________ Position Held: ____________________________

Address: ____________________________________________ City: _________________________________

State: __________________________ Zip Code: ______________ Phone Number: (       )_________________

Supervisor & Department: ____________________________________________________________________

Briefly Describe Your Duties: _________________________________________________________________

__________________________________________________________________________________________CoA-7 4/96; 2/07; 5/08, 6/08, 6/09

List other employment positions you have held:___________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Personal References:  Please list three (3) people from whom you can get letters of reference from to be placed in your volunteer file BEFORE you begin your volunteer activities:

           NAME                                      ADDRESS                                                       TELEPHONE NUMBER

1. _____________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________
 
 

 

 

 

 

 

 

 

 


MEDICAL HISTORY:

 

Do you have any physical, mental or medical impairments which may interfere with your ability to do the work for which have volunteered?  ƒ Yes    ƒ No

 If yes, please explain: _______________________________________________________________________

 

Your Physician’s Name: _______________________________ Phone Number: _________________________

May we contact them, if necessary, relative to your physical condition?   ƒ Yes    ƒ No

Are you currently taking any drugs or medication?   ƒ Yes    ƒ No

 If yes, please explain: _______________________________________________________________________

 

In Case of an Emergency CoA Should Contact:

Name: ______________________________________  Address: _____________________________________

Home Phone Number: ____________________________________ Relationship: _______________________

Work Phone Number: _______________________________ Cell Phone Number: _______________________

If your personal doctor is not available, can another trained medical attendant administer treatment? ƒ Yes ƒ No

Text Box: I certify that all the statements made in this application for volunteering are true, complete and correct to the best of my knowledge and belief. I also understand that any false information or omissions may result in my being asked to leave the Council on Aging volunteer program(s). _____________________________________________________ ________________________________ Signature of Applicant Date Signed Hospital Preference: ________________________________________________________________________