Skip to content
(574) 233-5433
1402 S. Michigan St, South Bend, IN 46613
Facebook
Home
About
About
Philosophy
Partnerships
Accreditation & Certification
Services
Residential Housing
Preparing for Recovery
Outpatient Therapy
Case Management
Specialized Treatment Sessions
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
Community
Events
Kernan’s Heroes Ride
Signs and Wine
Taste of Michiana
Trivia Night
More
Covid-19 Update
Donations
FAQ
Careers
Careers
Resources
Volunteer
Contact
Home
About
About
Philosophy
Partnerships
Accreditation & Certification
Services
Residential Housing
Preparing for Recovery
Outpatient Therapy
Case Management
Specialized Treatment Sessions
Aftercare/Continuing Care
Priority Consumers
HMIS Privacy Practices
Community
Events
Kernan’s Heroes Ride
Signs and Wine
Taste of Michiana
Trivia Night
More
Covid-19 Update
Donations
FAQ
Careers
Careers
Resources
Volunteer
Contact
Search
Close
Search
Close
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
Send
