Date received: _____________

LGBT FOCUSED RESIDENCE

VOLUNTEER APPLICATION Name ________________________________________ Preferred ______________________ First Last Address _____________________________________________________________________ Street City State Zip Daytime Phone ________________________ Evening Phone _________________________ Email __________________________________________DOB_________________________ mm/dd/yyyy

Is it okay to leave a message at: The best way to contact me is

Home Phone

Work

Cell

Email

Email

Preferred Pronoun (i.e. he, she, ze, they, etc): _______ Emergency Contact: ______________________________ Phone _______________________ Are you a returning volunteer?

Yes

No

How did you hear about the Volunteer Program at Mary’s House for Older Adults, Inc.? ______________________________________________________________________________ _____________________________________________________________________________ Why do you want to volunteer at Mary’s House for Older Adults, Inc.? _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ Tell us about yourself. What do you feel makes you a good fit for Mary’s House for Older Adults, Inc.’s volunteer program? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Revised 01/14

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Which volunteer Committee/Activity are you interested in? (check all that apply) Web Development/Maintenance

Accounting

Property Maintenance

Marketing

Fundraising: Events

Major gifts

Planned Giving

Campaigns

Grants

Program Development

Special

In-kind support

Corporate

Public Relations

Federal

Pro Bono Professional Service Specialty: __________________________________

----------------------------------------------------------------

Administrative/Office

Volunteer Management

Risk Management

Community Outreach & Education

Building Contractors

Project Management

Architects

Policy

Real Estate

Grant Developer

DC Government

Do you have any past volunteer experiences? If so, please provide the name(s) of the organization(s) as well as a brief description of what you did. Organization

Position/Tasks

Dates

Do you have any other special skills or professional certifications that might benefit our clients or organization (i.e. Legal, Capacity Bldg., Marketing, Web, IT, etc.)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Below, please list your general availability. Please remember that our volunteers are expected to commit to at least 4 hours per month. Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

When is the best time to reach you? We may have questions about your application or background check; let us know which of the following time frames is best to contact you. Wednesdays 10am – 12pm

Thursdays 10am – 12pm

Other _______________________________________________ Revised 01/14

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Time Commitment I understand that participation as a Mary’s House for Older Adults, Inc. Volunteer requires a minimum time commitment of four hours per month, and that I am to notify the Chair if and when I wish to discontinue volunteering with or without reason. _________ Initial Here

Insurance Information I understand that all volunteers must agree to allow Mary’s House for Older Adults, Inc. to run a base security check for insurance purposes. _________ Initial Here I understand that Mary’s House for Older Adults, Inc. does not insure drivers; my own insurance covers myself, my vehicle, my passengers, and all other damages during volunteer activities. _________ Initial Here

Confidentiality Statement I, _____________________________________________, am volunteering my time to work with Mary’s House for Older Adults, Inc. I understand that in the course of my volunteering I may learn information about an individual or the organization that is personal and confidential. Examples of such information include organizational strategies and finances, as well as individuals’ sexual orientation, economic status and relations with family/friends. I understand that all information must be treated as completely confidential. I agree not to disclose any information of a personal and/or confidential nature to any persons not affiliated with the Mary’s House for Older Adults, Inc. management without the specific written consent. I agree that if I have any doubt about a situation I will contact the President of Mary’s House for Older Adults, Inc.

_____________________________________________________ Signature

Revised 01/14

________________ Date

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