Students Playing, Learning, and Staying Healthy

Students Playing, Learning, And Staying Healthy

A ministry of Reformation Lutheran Church

in partnership with LFS Carolinas Refugee Office

Summer 2010 Volunteer Application

Name / /

Date:

Address /
City/State/Zip: /
Email: /

Occupation:

Evening Phone: /

Place of Employment:

Daytime Phone:
Birthday:
Summer SPLASH Volunteer Opportunities
Indicate volunteer position(s) you are interested in:
Classroom helper/tutor / Nap time monitor / Monitor food service / Transportation helper/ride on bus
Arts and Crafts Helper / Supervise play time / Chaperone field trips / Other
Music helper / Set up and serve meals / Administrative helper
Work experience and/or previous volunteer experience:
Special training (such as Red Cross certification, other applicable classes) :
Hobbies & Interests:
Please list any cross-cultural experiences:
Languages you can speak, write, or understand:
AVAILABILITY- When are you available to volunteer?
Full Week Opportunities: / 8:30 a.m. – 3:30 p.m.
June 7-11 / June 14-18 / June 21-25 / June 28 - July 2 / July 6-9 / July 12-16
Weekday Opportunities: / (select as many days and as many time slots as apply)
Mondays / Tuesdays / Wednesdays / Thursdays / Fridays
Hours: / 8:30 a.m. - 12:00 p.m. / 12:00 p.m. - 3:30 p.m. / All day
References:
How did you hear about us?
Please list the name and phone number of two references:
Name: / Phone:
Name: / Phone:
Emergency Contact Information
Name: / Relationship to you:
Home Phone: / Work Phone: / Cell Phone:
Have you ever been convicted of any offense other than a minor traffic violation with a fine of $200.00 or less? (A conviction will not necessarily be a bar to your acceptance as a volunteer.) YES NO
If yes, please explain the place, date, and disposition of any convictions:
I certify that all the information on this application is true and complete. I give permission
q  to Reformation Lutheran Church and Lutheran Family Services to request a confidential criminal records background check.
q  to let my photograph or quotes about SPLASH be used to promote and interpret this program.
It is legal for me to work in the United States.
I understand falsification or significant omission of information may be reason for non-acceptance or later release from a volunteer position.
Applicant’s Signature: / Date
Legal Guardian’s signature:
(for volunteer under 17) / Date

Please return this form by fax, email or postal mail to:

Gloria Preslar, SPLASH Volunteer Coordinator

Reformation Lutheran Church

1118 Union Street

Columbia, SC 29201

Fax: 803/252-1508