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Life Treatment Centers |
1402 S. Michigan St, South Bend, IN 46613 |
(574) 233-5433

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Volunteer

Volunteer Application Form

Name*

Email*

Street Address*

City*

State*

Zip*

Phone Number*

Are you at least 18 years old*

Best time to be reached

Do you have reliable transportation*

Emergency Contact Name*

Relationship*

Best Emergency Contact Number*

Education Information

High School Name & Location*

Years Completed*

Degree

College Name & Location

Years Completed

Degree

Trade School Name & Location

Years Completed

Degree

Recent Employment Information

Employer Name & Company

Position

Dates Employed

Currently Employed

Employer Name & Company

Position

Dates Employed

Currently Employed

Volunteer History

Agency, Position(s) Held, Dates Served

Other Relevant Experience

Have you had any experience working with persons with chemical dependencies? If yes, explain:

What do you wish to gain from volunteering at Life Treatment Centers?

Have you been convicted of a felony*

Are you volunteering through an organization?

Organization Name

Referred or Prompted by

Placement

Interests / Hobbies

List any special skills/training

What work gives you satisfaction

Please check any and all areas of interest:

Clerical Work

Educational Assistance

Legal Assistance

Treatment Assistance

After-hours Reception

Making Sack Lunches

Kitchen Assistance

Maintenance

Development Assistance

Follow-up Calling

Chart Breakdown

Availability:*

List Three (3) References

Reference Name (1)*

Years Known

Phone*

Mailing Address

Email*

Relationship

Reference Name (2)*

Years Known

Phone*

Mailing Address

Email*

Relationship

Reference Name (3)*

Years Known

Phone*

Mailing Address

Email*

Relationship

I state that my answers on this form are true and correct to the best of my knowledge.

Signature*

Date*

Attention: You must complete every element of the form before submission. Any fields with only spaces will prevent the form from submitting.

Error:

*Revised 04/01/2017

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