Loading...
Life Treatment Centers |
1402 S. Michigan St, South Bend, IN 46613 |
(574) 233-5433
Home
About
About
Philosophy
Accreditation & Certification
Board of Directors
Partnerships
Services
Tobacco Free Recovery
After Care/Continuing Care
Priority Consumers
Residential Housing
Case Management
Outpatient Therapy
Specialized Treatment Sessions
HMIS Privacy Practices
Community
Veterans Program
Events
Kernan's Heroes Ride
Joe vs Joe
Taste of Michiana
Signs and Wine
More
COVID-19 Update
Donations
Videos
FAQ
Careers
Application & Job Postings
Resources
Volunteer
Contact
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:
Submit
*
Revised 04/01/2017
