Name *
Address *
Phone *
Over 18? *
Please list language(s) as well as specify whether you can write, read and/or speak.
Do you have access to reliable transportation? *
Are you presently employed? *
Check as many as apply:
Would you be willing to be “on-call” for special assignments? *
Emergency Contact 2 Phone *
Emergency Contact 2 Phone
Emergency Contact 2 Phone *
Emergency Contact 2 Phone
One day, a month, a semester, indefinitely?
Please include the following: IN OUT MONDAY ___________ ___________ TUESDAY ___________ ___________ WEDNESDAY ___________ ___________ THURSDAY ___________ ___________ FRIDAY ___________ ____________ SATURDAY ___________ ____________
Include the following information for each of your 3 references: Name Position Organization Phone Email Address
Would you like to be added to our mailing list? *
Would you like to volunteer in the Central Valley or Bay Area? *
Would you like to become a member of SIREN for $25? *
Would you like to donate to SIREN? *
I hereby certify that all statements made in this application are true and I authorize investigation of all matters contained in the application. I acknowledge that any false statements or misrepresentation on this application will be cause for refusal of placement or immediate dismissal at any time during the period of my placement. I am aware that fingerprinting may be required before placement in certain areas or departments. I am here of my own will and accord volunteering my services and time to be used according to the assignments of SIREN with the understanding that this agreement may be terminated at any time by myself or by SIREN without reason or notice. I do not expect any type of compensation, in money or in kind, for my volunteering. (Parent/Guardian signature required for volunteers under 18 years of age): The signature of my parent/guardian below serves as permission and general release from liability during my time as a volunteer for SIREN. *
By checking this box, you agree to the following statement above on the date this form is submitted.