* = Required Field

First Name: * Last Name: *

Address: *

City: * State:  *   Zip: *

Home Phone: *     Work Phone:

Email Address:   *

Are you over the age of 18:   Yes No

Employer or School:  

If you are a student....

Major:       Year in School: Elementary Student Middle School/Jr High Student High School Student College Student Not currently a student

Availability... place a check in the box for the times you are available:

How many hours per month do you wish to volunteer?

Do you have access to transportation? Yes No Select one

Do you have any physical limitations that you wish to consider in your volunteer placement?

Previous Work Experience:

Previous Volunteer Experience:

Hobbies, interests, skills:

Special training or certification:

The following are volunteer needs within the City. Please check those areas that interest you:

Are there City departments that you have a specific interest in working with?

Education:

Select highest grade completed: 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade College 1 yr College 2 yr College 3 yr College 4 yr Masters Degree MD or PhD Select One

Specialized or Military training:

How did you hear about the City volunteer program?

Why do you want to volunteer for the City?

In case of an emergency contact:

Name: Relationship:

Home Phone: Work phone:

References:

List two references, not related to you, who are familiar with your volunteer, civic, career or educational experiences.

Name: Phone:

Name: Phone:

Do you have any criminal convictions (other than parking violations)? yes no Select One

If yes, please explain where, when, and disposition:

I understand that I am not an employee of the City of Columbia and that duties that I perform are as a volunteer. If the City has established procedures for the performance of volunteer duties assigned to me, I agree to follow those procedures. I also understand that it is my responsibility to update any address, emergency contacts or other information on this form. I understand that for certain positions, a background check may be conducted before I am placed as a volunteer with the City of Columbia and I agree to cooperate in the background check.

Please verify your information before selecting submit.