STUDENT INFORMATION

Name:

Address:

City: State: Zip:

Home Phone:

Please Describe Your Previous Volunteer Experience :

When are you available to volunteer?

Term 1: December / January - 6 weeks
Term 2: January / February - 8 weeks
Term 3: March / April - 8 weeks
Term 4: April / May 6 weeks

Volunteering for:

Cedar Lake Lodge
Cedar Lake Residences
To be determined

Other skills and special interests:

BACKGROUND

Have you ever been convicted of a misdemeanor or criminal offense? yes no

If yes, please explain:

(A conviction does not automatically mean you cannot volunteer. The nature of the offense and how long ago are important. Use additional sheets if necessary. Give all facts so an appropriate decision can be made.)

PERSONAL REFERENCES Please list two people whom you have known for at least one year and can attest to your character, skills and dependability. Do not include relatives.

Name:

Address:

City: State: Zip:

Relationship:

Name:

Address:

City: State: Zip:

Relationship:

PERSON TO CONTACT IN CASE OF EMERGENCY

Name: Relationship:

Day Phone:      Evening Phone:

PLEGE OF CONFIDENTIALITY

By clicking the submit button, I hereby pledge that I shall safeguard and treat as confidential or protected information (whether acquired through verbal communication, written record, or observation) pertaining to any client, relative or friend of any resident or client, staff member, or volunteer of Cedar Lake, which I may through my affiliation with the agency, so acquire. I agree to have read and understand the foregoing plege of confidentialty.