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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
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City
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State
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Zip
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Phone Number
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Are you at least 18 years old
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Best time to be reached
Do you have reliable transportation
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Emergency Contact Name
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Relationship
*
Best Emergency Contact Number
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Education Information
High School Name & Location
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Years Completed
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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:
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List Three (3) References
Reference Name (1)
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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
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Date
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Attention:
You must complete every element of the form before submission. Any fields with only spaces will prevent the form from submitting.
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Revised 04/01/2017
