Volunteer Application

Volunteer

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Salutation

First Name *

Middle Initial

Last Name *

Address (Line 1) *

Address (Line 2)

City *

State *

Zip Code *

Primary Phone *

Cell Phone

Email Address *

Employer (optional)

Work Phone

Is it appropriate to call you at work?

Yes

School (if currently a student)

Birth Date *

Month

Day

Year

Church Affiliation (optional)

Volunteer position for which you are applying?

Have you ever been convicted of a crime? *

Yes

If yes, please explain

Have you ever been an employee of LSS? *

Yes

If yes, please list program or service/position/dates of most recent employment.

LSS Program or Service

Position

Employed From:

Month

Day

Year

Employed To:

Month

Day

Year

Please note any health or physical limitation that you may have (including allergies); or need for any specific accommodations

Please list your special skills, interests or hobbies

Please list any certifications or credentials you hold

Previous or current occupations

Previous or current volunteer positions

How did you learn of this volunteer opportunity?

Languages spoken (other than English)

Availability

	8am-Noon	Noon-4pm	4pm-8pm
Sunday	Sunday - 8am-Noon	Sunday - Noon-4pm	Sunday - 4pm-8pm
Monday	Monday - 8am-Noon	Monday - Noon-4pm	Monday - 4pm-8pm
Tuesday	Tuesday - 8am-Noon	Tuesday - Noon-4pm	Tuesday - 4pm-8pm
Wednesday	Wednesday - 8am-Noon	Wednesday - Noon-4pm	Wednesday - 4pm-8pm
Thursday	Thursday - 8am-Noon	Thursday - Noon-4pm	Thursday - 4pm-8pm
Friday	Friday - 8am-Noon	Friday - Noon-4pm	Friday - 4pm-8pm
Saturday	Saturday - 8am-Noon	Saturday - Noon-4pm	Saturday - 4pm-8pm

I am available to volunteer with the following frequency:

Days per week

Days per month

As needed

Emergency Contact:

Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Primary Phone

Cell/Work Phone

Relationship

Reference #1 (not relatives):*

Name *

Address (Line 1) *

Address (Line 2)

City *

State *

Zip Code *

Primary Phone *

Relationship *

Reference #2 (not relatives):*

Name *

Address (Line 1) *

Address (Line 2)

City *

State *

Zip Code *

Primary Phone *

Relationship *

For Stephen Ministry Applicants only, please list your pastor as reference #3:

Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Primary Phone

Relationship

Notice of Privacy Statement | Non-Discrimination Policy

Lutheran Social Services South Central Pennsylvania, 1050 Pennsylvania Ave., York, PA 17404

888.404.3500 | 717.854.3971

Volunteer Application

Volunteer

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