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Participant Application -- Volunteer Application

Participant Application

Name: Date:

Address:

Birth date: Grade: School:

Mother's Name:

Home Phone #: Work Phone #:

Father's Name:

Home Phone #: Work Phone #:

Please list any activities in which your child has had previous involvement

(e.g.: Community, Recreational, Extracurricular Programs, etc.):

Please list the activities in which your child is interested in participating
(e.g.: Boy/Girl Scouts, School of Religion, Sports, School-related Activities, Community/Recreational Programs, etc.):

Activity: Day: Time:

Do you need more information about the activities: q Yes q No

If yes, please list:

Please describe your child in the following areas:

Communication Skills (How well is your child able to understand and follow verbal directions? Does he or she use other forms of communication, for example, sign language?)

Level of Independence (What level of assistance would help your child feel

successful?)

Please share with us any other information that would be helpful to your child's

success in this program:

How do you hope your child will benefit from this activity?

Would you like us to contact your child's teacher? __ Yes __ No

Teacher's Name:

Teacher's Phone #:

Parent's Signature:

Student Volunteer Application

Name: Date:

Address:

Birth date: Grade: School: Phone Number:

Previous Participation in Volunteer Activities:

Personal Interests/Hobbies:

Personal attributes that would contribute to your ability to provide support to a

person with a developmental disability:

Are there certain extracurricular/community activities for which you particularly

enjoy providing support?

Please check the days and indicate the time that you are available:

Monday Friday

Tuesday Saturday

Wednesday Sunday

Thursday

Please share with us any information about yourself or your experiences that may be helpful:

Please provide two unrelated references that we may contact:

Name: Name:

Address: Address:

Phone #: Phone #:

For Office Use Only

Relationship with the volunteer: Relationship with the volunteer:

How long have you known the volunteer? How long have you known the volunteer?

List characteristics of the volunteer List characteristics of the volunteer

(e.g.: responsible, reliable, etc.): (e.g.: responsible, reliable, etc.):

Do you have any knowledge of the Do you have any knowledge of the

volunteer's experience working with volunteer's experience working with

children? Please explain. children? Please explain.