Volunteer Application - Interval House

CONTACT INFORMATION

Name*

Prefix First Last

Date of Birth*

(Volunteers/Interns must be at least 18 years old)

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Evening Phone*

Email*

May we add you to our mailing list?

Yes
No

What is the best way to contact you?

OCCUPATION

Present Occupation

Employer

Length of Service

Do you have a valid driver's license and reliable transportation?*

Yes
No

VOLUNTEER OPPORTUNITIES

What volunteer opportunities interest you?*

What volunteer opportunities are you interested in?

* Please note that direct service volunteers are required to complete comprehensive advocacy training before serving in any advocacy role, and those volunteers must commit to consistent service for a term no shorter than one year or 120 total hours in addition to training (10 hours per month). If this time commitment is not possible for you, please consider other volunteer opportunities.

BACKGROUND INFORMATION

Have you ever been convicted of a crime other than a minor traffic violation?*

Yes
No

Please explain and give dates

Are you seeking an internship with Interval House?

Yes
No

If yes, where are you a student?

Major

Undergraduate or Graduate Student?

Graduation Year

AVAILABILITY

Will you be able to make a time commitment for one year?*

Yes
No

If no, please specify how long

When are you available to volunteer?*

When is your primary availability? Please list hours. (Note: We operate seven days a week — 24 hours a day)

How many times per month?

VOLUNTEER EXPERIENCE

Please list any volunteer experience you feel is applicable.

Organization

Supervisor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Start Date

End Date

Duties

Organization

Supervisor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Start Date

End Date

Duties

PERSONAL BACKGROUND

Languages you speak

What skills, training or knowledge do you want to utilize at Interval House?

Are you comfortable working with and/or being around children?*

Yes
No

Are you or someone close to you a survivor of domestic abuse?

Yes
No

If so, please explain

(All answers will be kept confidential.)

If you have had personal experience with domestic violence, please tell us how you feel this will affect your work as a volunteer

(All answers will be kept confidential.)

Have you received services from Interval House or another DV organization?

Yes
No

If so, what year?

Give an example of a time you have worked with people from different ethnic and socioeconomic backgrounds. How did you feel?

What, if any, life experiences do you feel strengthened you for this role?

What concerns do you have about doing this type of work?

What attracted you to Interval House?

EMERGENCY CONTACTS

Please list two emergency contacts should a situation arise when you are volunteering

Name*

First Last

Phone*

Relationship*

Name

First Last

Phone

Relationship

REFERENCES

Please list three personal or professional references. Please exclude relatives.

Name*

First Last

Phone or Email*

Relationship*

Name*

First Last

Phone or Email*

Relationship*

Name*

First Last

Phone or Email*

Relationship*

On behalf of Interval House, I would like to thank you for your offer to volunteer with us. We greatly appreciate it and could not do what we do without our volunteers. If you have a question, you can leave a voicemail message at 860-246-9149 ext. 350 and I will return your call as soon as I can. Sincerely, Penni Micca Director of Volunteer Services

Phone

This field is for validation purposes and should be left unchanged.