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Volunteer Application

HomeSafe, Inc.

Please note: all information is protected under HomeSafe’s Confidentiality Policy

Please print:

Last Name:                                                                                                                                       

First Name:                                                                                                                                      

Middle Name:                                                                                                                                  

Nickname:                                                                                                                                        

Mailing Address:                                                                                                                             

Apartment, Lot or Suite Number:                                                                                                    

City:                                                                            State:                Zip Code:                            

Home Telephone Number:                                             Cell Telephone:                                        

Work Telephone:                                          Email Address:                                                           

Date of Birth (dd/mm/yyyy):                                                            

Educational Level: ________________________________

Current Occupation: _______________________________

Optional: Are you a survivor of domestic abuse?                            Yes                   No

Emergency Contact:

Last Name:                                                                 First Name:                                                 

Relationship:                                                              Best Telephone Number:                            

Availability:

Do you need the volunteer hours for school/college credit?         Yes / No

If yes, how many hours?                         

Is there a time frame or deadline for completing these hours, please list dates:                             

Are the volunteer hours needed for Community Service credit?        Yes / No

If yes, how many hours? __________

Is there a time frame or deadline for completing these hours, please list dates: ____________

Days and times available: _______________________________________________________

Have you ever been employed or volunteered with a program that addressed domestic violence, sexual assault, or child abuse? If so, please list agency, years employed and your position:         

                                                                                                                                                          
 
 Volunteer opportunities at HomeSafe encompass a variety of positions and tasks.  The following is a partial list of activities to consider.  Please circle any you might be interested in and would like to have additional information on.
 

Children

Store Room

Office

Helpline and Helpline Back Up

Advocate

Community Outreach

Clerical

Peer Counseling

Maintenance

YouthSafe Program

Board Committee