21St Century Clubhouse After School Program

21st Century Clubhouse After School Program

VOLUNTEER APPLICATION

Date: _____ / _____ / _____

First Name: ______Last Name: ______

Home Address (for mailing purposes): ______

Work Address: ______Email: ______

Home Phone: ( ____ ) _____ - ______Cell Phone: ( ____ ) _____ - ______

How would you prefer to be contacted? (circle) home work email fax

------DEMOGRAPHICS

DOB: _____ / _____ / _____ Age: ______Sex (circle): Female or Male

(for funding purposes only) Ethnicity: ______Religion: ______Marital Status: ______

Language(s) spoken: ______

------WORK EXPERIENCE

Name of company you work for: ______How long? ______

Job Title: ______

------

EMPLOYMENT / CAREER BACKGROUND (include any special training; feel free to attach a resume, instead of answering below)

Your skills: ______

Your hobbies and personal interests: ______

Affiliations with other organizations (include any relevant contacts with community organizations, etc.):

______

Educational Background: ______

______

Current and Past Volunteer Experiences: ______

______

Past Experience working with children:

______

TUTOR/STUDENT MATCH PREFERENCES

Tutoring Subject(s): ______

Day\Time Preference: (circle all that apply):MONDAY TUESDAY WEDNESDAY THURSDAY

3:30-4PM 4PM-4:30PM 4:30PM-5PM 5PM-5:30PM

Thank you for your interest! We greatly appreciate our volunteers.