Last Name
|
First
Name
|
Middle
|
|
| The
following questions in blue are optional. |
| Age: |
Youth (0-18)
|
Young Adult
(19-25)
|
Adult (26+)
|
| Ethnic
Group: |
Black
|
Hispanic
|
Asian/Pacific
Islander
|
|
White
|
American
Indian/Alaskan Native
|
Other
|
| Gender: |
Male
|
Female
|
|
|
Home Address
|
City
|
State
|
Zip Code
|
|
Business Address
|
|
|
City
|
State
|
Zip Code
|
|
Home Phone
|
Business Phone
|
|
Fax
|
E-mail
|
|
|
|
Experience - paid & volunteer work experience beginning
with present/most recent.
|
Organization #1
|
Phone
|
Address
|
Work performed or
title
|
Dates (from/to)
|
Supervisor
|
|
Organization #2
|
Phone
|
Address
|
Work performed or title
|
Dates (from/to)
|
Supervisor
|
|
Organization #3
|
Phone
|
Address
|
Work performed or title
|
Dates (from/to)
|
Supervisor
|
|
Professional
License(s)
|
Type
|
Number
|
|
State
|
Expiration Date
|
|
|
| Education/Training (beyond high school - start with
current/most recent) |
Name of institution(s)
|
City/State
|
Degree
|
|
| Fluent Language Skills, including sign - other than English |
Speak and Understand
|
Read Translate
|
Write
|
|
| Volunteer Opportunities - please check areas of interest |
|
Blood
Services |
Disaster
Services |
Administrative |
|
Leadership |
First Aid/CPR |
Special
Events |
| Presenter/Educator |
Recruitment |
Teaching |
| Communications/PR |
Service to Military |
School
Clubs |
| International
Services |
Computers |
Fundraising |
|
Grant Writing |
Youth
Program |
Transportation |
|
Community
Outreach |
Receptionist |
|
|
| Availability: (please check) |
| M
T W
Th F
Sa Su AM
PM |
Starting Date
|
|
|
Emergency Contact |
Name
|
Phone
|
Address
|
|
| References:
List two references (do not include
relatives) |
Name
|
Address
|
Phone
|
|
Have you ever worked as a paid Red Cross employee?
YES NO If yes, give position,
location, dates.
|
|
| A yes answer to any of the questions below will not
necessarily disqualify an applicant. |
|
Are you
licensed to operate a motor vehicle in this state?
YES
NO
Has your license ever been revoked: (if yes,
explain)
YES
NO
|
|
Have you ever been convicted of a felony or, with the past 24
months, of a misdemeanor that resulted in imprisonment? (if yes,
explain)
YES NO
|
|
Have you ever had any Red Cross authorizations (Health and
Safety Instructor, DSHR member)? If so, what?
YES
NO
|
|
Has it ever been revoked? (if yes explain)
YES
NO
|
|
Reason for volunteering at the American Red Cross
(optional)
|
|
|
Volunteer Consent for Reference
and Background Checks
I do hereby give the American Red
Cross permission to inquire into my educational background, driving record,
employment, volunteer history, or police record. I further give
permission to the holder of any such records to release the same to the
American Red Cross.
I hereby hold the American Red
Cross harmless of any liability, whether civil or criminal that may arise as a
result of the release of this information about me. I further hold
harmless any individual, agency, business, or corporation that provides
information or documents to the above named American Red Cross unit.
I understand that the American Red
Cross will use this information as part of its verification of my volunteer
application.
|
|
Name/Signature
|
Date
|
|
|
|