Volunteer Service Application

SERVICE APPLICATION

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Home Phone*

Cell Phone

Your Email (required)

Place of employment:

How did you hear about Mother Teresa House?

What, if any, volunteer work have you done?

Have you ever been convicted of a crime?
YesNo

If yes, please explain

Are there any felony charges pending against you?
YesNo

If yes, please explain

Have you been involved in hospice care? In what way?

Our mission is to give personal care to our terminally ill guests. Are you interested in giving hands-on care?

Are you interested in serving as an Ambassador - bringing 10 new people on a Tour of Peace over a 3 month period (with the help of our development leader)?
YesNo

Availability

How many hours per week/month might you be available?

Please indicate the times best for you:

Sunday
MorningAfternoonEveningOvernight
Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
MorningAfternoonEveningOvernight

Comments:

When can you begin?

Is there anything else you would like to tell us about yourself (i.e. interests, family, jobs, etc.)?

References: Please provide two to three references and their contact information. These may include employer, pastor or teacher.

Reference 1:

First Name

Last Name

Phone

E-mail

Relationship to you:

Reference 2:

First Name

Last Name

Phone

E-mail

Relationship to you:

Reference 3:

First Name

Last Name

Phone

E-mail

Relationship to you:

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