American Red Cross of Monroe County

Monroe County Chapter
VOLUNTEER APPLICATION


Date		Date of Birth
Age Group	(14-18) (19-24) (25-64) (65 and over)
Contact Information
Last Name		First Name
Middle Name

Home Address		Apt/Bldg
City		State
Zip Code

Business Address		Apt/Bldg
City		State
Zip Code

Home Phone		Business Phone
Cell Number		Fax Number
Email Address
My preferred mailing address is: Home Address Business Address

Employer		Occupation
Emergency Contact
Name		Day Phone
Evening Phone		Relationship
Experiences (include both paid and volunteer work experience, beginning with most recent)
Organization Name		Address
Phone		From To
Supervisor's Name/Title

Organization Name		Address
Phone		From To
Supervisor's Name/Title
Current Licenses and Certifications (other than those received through the Red Cross)
Type		Number
State		Expiration Date

Type		Number
State		Expiration Date
Education (highest level achieved)
Institution Name		City/State
Degree/Major		Date Attended
Language Skill Proficiencies
Language
Speak	High Medium Low
Read	High Medium Low
Write	High Medium Low

Language
Speak	High Medium Low
Read	High Medium Low
Write	High Medium Low

Skills (please check up to four from the list)
Accounting	Filing	Public Relations
Administrative Support	Financial Consultant	Public Speaking
Communications	Fund Raising	Teaching
Computer Support	Graphic Design	Technical Writer
Counseling	Journalism	Volunteer Advisor
Data Entry	Management	Other(specify)
Driving	Photography
Events Coordination	Project Management

Availability
Monday AM	Tuesday AM	Wednesday AM	Thursday AM	Friday AM
Monday PM	Tuesday PM	Wednesday PM	Thursday PM	Friday PM

Previous Red Cross Experience

Have you ever worked as a Red Cross employee or volunteer? Yes No

(If yes, give Red Cross affiliation names, position and dates.)

Have you ever held any Red Cross Certification? Yes No

(If yes, please list)

A "yes" answer to the following italicized questions does not necessarily disqualify an applicant.

Have you ever been convicted of a felony or misdemeanor? Yes No

If yes, please explain.

Note: Volunteers will be precluded from service if the background check shows a court imposed penalty for a crime within the past 7 years from the date of disposition, releast from jail or prison, or release from probation or parole, whichever occurs latest.

Have any of your Red Cross certifications ever been revoked? Yes No

If yes, please explain.

Why do you wish to volunteer with the American Red Cross(optional):

In an effort to assure your safety and the safety of those we serve, the American Red Cross requires that all Red Cross employees and volunteers complete a background check prior to employment or registered volunteer service.

Signature: Date:

Consent of Parent/Guardian for Applicant Under Age 18

Signature: Date:

Name:

Statistical Information

The American Red Cross, in recognition of its responsibility to employees, volunteers, and the community it serves, reaffirms its policy to assure fair and equal treatment in all of its practices, for all persons. The American Red Cross will not discriminate on the basis of race, color, religion, sex or national origin, or against any qualified handicapped individual, disabled veteran or veteran of the Vietnam era. The following information is requested only to determine the diversity of Red Cross volunteers.

While Completion is optional, it would be most helpful to us as we monitor the complete record of our program.

Gender	M F
Veteran	Yes No
Disabled	Yes No
Marital Status	Married Single Divorced Widowed
Ethnic group	Hispanic or Latino White (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Asian (Not Hispanic or Latino) American Indian or Alaska Native (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino)