Volunteer Form

Salutation:

Mr. Mrs. Ms. Dr. Other

First Name*:

Last Name*:

Home Phone*:

Address*:

Apt./Ste.:

City*:

State/Prov.*:

Postal Code*:

Email*:

Employer:

Position Title:

Work Address:

Work Phone:

In Case of Emergency, Notify:

Name:

Relationship:

Phone:

Volunteer Experience: Position, duties, dates:

Education:

Areas or Interest/Degrees:

Are you over 18:

Yes No

Volunteering for school credit:

Yes No

Languages other than English:

Relevant Information:

Why do you want to volunteer?:

How did you hear about us?:

Time(s) Available:

Preference for specific volunteer activity:

Clinic Escort

Education Aide

Development Aide

General Office Aide

Would you accept another activity for which you would recieve training?

Other Activity:

Yes No

Other Comments:

Professional References (enter 2 volunteer, work or school references)

Name*:

Relationship*:

Telephone*:

Name*:

Relationship*:

Telephone*:

By checking this box, I agree to conform with Planned Parenthood of San Antonio and South Central Texas's rules and regulations to the best of my ability. I agree to respect the confidentiality of all patient/client/donor information which I gain either directly or indirectly in my work. I assert that the information furnished on this application is true and correct to the best of my knowledge. I further understand that any breach of this agreement constitutes grounds for immediate dismissal.

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