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Volunteer Application

Please print and mail or fax to the address below.

Name:_______________________________________________________________

E-Mail Address:_______________________________________________________

Address:_____________________________________________________________

City:_______________________________ State: ____ Zip:___________________

County:____________________________ Age (if under 19):_____

Permanent Address (if different from above): _______________________________

_____________________________________________________________________

Home Phone:_______________________

Work Phone: _______________________

Place of Employment:__________________________________________________

Please answer the following questions. If more space is needed, please attach additional sheets.

1. Why are you interested in volunteering with Ele's Place?

2. What type of volunteer work are you interested in? Please check one or more of the choices below.  Click on Volunteer Opportunities for descriptions of each option.

Support Group Program-related Volunteer Opportunities:

__ Support group facilitator (working with children)

__ Support group program helper (assisting with greeting, activity room and/or library)

 

Other Volunteer Opportunities:

                         __ Office work (receptionist, data entry, etc.)

                         __ Helping with special projects (please check those which are of most interest to you)
                                      __ Serving as an outreach ambassador of Ele's Place
                                      __ Delivering brochures (as assigned)
                                      __ Assisting with fund-raising events

                         __ Building or garden care volunteer
                                      __ Garden care volunteer (outside work)
                                      __ Building care volunteer ("handy-man" or similar work inside)
                                                                        

** If you are not interested in working directly with the Ele's Place support group program, please skip #3-5, and answer #6-7.  If you are interested in being a support group facilitator or program helper, please complete all of the questions.

3. Describe your experiences in working with children:

4. Have you experienced the death of a family member or close friend?  How long has it been since the death(s)?  Please briefly describe how the person(s) in your life died and how you coped with the experience(s).

5. Do you have clinical certifications or degrees (MSW, LLP or similar)?        YES     NO
 

If yes, please describe: ____________________________________________________________

6. Have you ever been convicted of any felonies or misdemeanors (other than for a minor traffic offense)? Please circle one.      YES     NO

If yes, please explain: _____________________________________________________________

7. Please list previous and current volunteer experiences:

Organization                Type of Volunteer Work               Supervisor                      Dates

I agree to give permission to Ele's Place to contact my volunteer supervisor(s) and I release my supervisor(s) from any liability for supplying information about my performance and suitability as a volunteer.

Signature _________________________________________ Date _______

** We strive to recruit volunteers that represent the diversity of our community.  With this in mind, we would appreciate it if you would provide the following information:

Gender: Please circle one.          MALE     FEMALE

Ethnicity: __________________________________

Thank you for your interest in being an Ele's Place volunteer!

Please return your completed application to the address listed below:

Ele's Place
1145 W. Oakland
Lansing, MI 48915

or Fax 517-482-6608

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