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(574) 233-5433
1402 S. Michigan St, South Bend, IN 46613
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Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
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Recovery Residency
Preparing for Recovery
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Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
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Frequently Asked Questions
Videos
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Careers
Resources
Volunteer
Contact
About
About
Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
Services
Recovery Residency
Preparing for Recovery
Admissions
Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
News
More
Donations
Frequently Asked Questions
Videos
Stories
Careers
Careers
Resources
Volunteer
Contact
Search
About
About
Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
Services
Recovery Residency
Preparing for Recovery
Admissions
Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
News
More
Donations
Frequently Asked Questions
Videos
Stories
Careers
Careers
Resources
Volunteer
Contact
About
About
Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
Services
Recovery Residency
Preparing for Recovery
Admissions
Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
News
More
Donations
Frequently Asked Questions
Videos
Stories
Careers
Careers
Resources
Volunteer
Contact
Search
About
About
Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
Services
Recovery Residency
Preparing for Recovery
Admissions
Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
News
More
Donations
Frequently Asked Questions
Videos
Stories
Careers
Careers
Resources
Volunteer
Contact
About
About
Philosophy
Partnerships
Payments Accepted
Accreditations & Certifications
Services
Recovery Residency
Preparing for Recovery
Admissions
Outpatient Therapy
Case Management
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
News
More
Donations
Frequently Asked Questions
Videos
Stories
Careers
Careers
Resources
Volunteer
Contact
Volunteer Form
Name
Email
Street Address
City
State
Zip Code
Phone Number
Are you at least 18 years old?
Yes
No
Best time to be reached
Do you have reliable transportation
Yes
No
Emergency Contact Name
Relationship
Best Emergency Contact Number
High School Name & Location
Years Completed
Degree
College Name & Location
Years Completed
Degree
Trade School Name & Location
Years Completed
Degree
Employer Name & Company
Position
Dates Employed
Currently Employed
Yes
No
Employer Name & Company
Position
Dates Employed
Currently Employed
Yes
No
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
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
Monday Availability
Tuesday Availability
Wednesday Availability
Thursday Availability
Friday Availability
Saturday Availability
Sunday Availability
Comments
Reference #1 Name
Years Known
Phone
Mailing Address
Email
Relationship
Reference #2 Name
Years Known
Phone
Mailing Address
Email
Relationship
Reference #3 Name
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
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