ST LOUIS SOCIETY FOR THE BLIND AND VISUALLY IMPAIRED VOLUNTEER INFORMATION FORM

* = Required Information

*Name:

Birth Date:

Street Address:

City:

State:

ZIP Code:

*Preferred Phone:

*Email:

Employer/School:

Position/Year:

EMERGENCY CONTACT INFORMATION

*Emergency Contact name:

Relationship to volunteer:

*Phone #1:

Phone #2:

When are you available to volunteer? NOTE: Typical volunteer hours will be Monday through Friday, 9:00am – 3:00pm. Evening and weekend opportunities are limited to special events. Please check all that apply: Monday time available: Tuesday time available: Wednesday time available: Thursday time available: Friday time available:

Do you require any special accommodations to volunteer?

Yes No

Please describe briefly:

Please list previous volunteer experience:

Please list any skills/abilities that you would like to utilize as a volunteer:

Please list any tasks you would not be capable of performing:

I understand that I am applying for a volunteer position and may not accept payment for my services. I agree to abide by the rules and regulations of the volunteer program or policies and procedures of the Society for the Blind and Visually Impaired, particularly related to confidentiality. I will sign any necessary documents to release information maintained by local, state or federal agencies. The statements on this form are true, complete and accurate.

Name (please print):

Signature: If submitting electronically, please type your name in the signature field to indicate acceptance/accuracy of above information.

Date:

You may also print this form and mail to: Volunteer Coordinator Society for the Blind and Visually Impaired 8770 Manchester Road St. Louis, MO 63144