Volunteer and Intern Form

Name: *

Date: *

Address: *

City: *

State: *

Zip: *

Phone: *

Email: *

Fax:

Best time to contact: *

If no, Parent/Guardian Name and Contact Number:

How did you hear about Planned Parenthood Greater Memphis Region (PPGMR)? *

Why are you interested volunteer with PPGMR?

What would you like to gain from your experience as a PPGMR volunteer?

If you have worked and/or volunteered for Planned Parenthood,, state where/when, final position and reason for leaving.

B. PREVIOUS VOLUNTEER EXPERIENCE

Organization

Position & Duties

Start Date

End Date

Organization

Position & Duties

Start Date

End Date

C. REFERENCES

Name

Relationship

Organization/Agency

Phone Number

Name

Relationship

Phone Number

Organization/Agency

D. INTERNSHIP/COMMUNITY SERVICE INFORMATION

If so, how many hours are required?

Time Commitment

School Name:

Degree:

Area of Study:

Internship Objectives:

E. AREA(S) OF INTEREST

F. SCHEDULING

Please note any seasonal, school, travel, or other scheduling difficulties:

G. OTHER INFORMATION

Do you have any special skills that you could use in a volunteer placement (computer skills, research, counseling/medical training, etc.)?

Do you have any special areas of interest that you could use in a volunteer placement?

Do you have any additional questions?

Are you a robot? *