The Children’s Hospital of Philadelphia

Homeless Health Initiative(HHI)

Volunteer Candidate Information Form

Name:______Date: ______

Address: ______

City: ______State: ______Zip: ______

Phone number(s):______

E-mail address: ______

Date of Birth: ______

I am currently a (please check all that apply):

___ CHOP employee

___ University of Pennsylvania student

___ University of Pennsylvania employee

Occupation: ______

Special professional training, skills, hobbies: ______

______

______

Community affiliations: ______

______

______

Previous volunteer experience: ______

______

______

How did you initially learn about HHI? (check any that apply and supply details as requested)

__ CHOP

__ Website

__ School (please specify) ______

__ Friend/Colleague (Please specify) ______

__ Shelter (Please specify) ______

__Other (Please specify) ______

Please take a moment to answer the following question:

What are you expecting/hoping to gain from this volunteer experience?
______

______

______

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CHOP Homeless Health Initiative - Volunteer Candidate Information Form

Name:______Date: ______

How would you like to volunteer? (Please check all that apply):

__ Participate in special events (i.e.,Back to school, Mother’s Day, Holiday celebrations)

__ Facilitateactivities in shelter, such as:

__ Child-development

__ Nutrition education workshops

__ Fitness workshops

__ Interactive parent-child engagement

__ Facilitatedonation drives (i.e.,food, clothing, book drives)

__ Assist with clerical program needs

__ Advocacy projects (i.e., letter writing, research projects, book club)

__ Other (please describe):

______

Availability

Please indicate your available days and times to volunteer by shading in the corresponding boxes.

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
9-10 a.m.
10-11 a.m.
11 a.m.-noon
Noon-1 p.m.
1-2 p.m.
2-3 p.m.
3-4 p.m.
4-5 p.m.
5-6 p.m.
6-7 p.m.
7-8 p.m.
8-9 p.m.

How many hours per week or month do you wish to commit? ______

What is the overall length of time you wish to commit (i.e., once, 6 months, ongoing)?

______

Thank you for your interest in volunteering for the CHOP Homeless Health Initiative!

You will be added to our database of potential volunteers and may be contacted soon

regarding a new volunteer orientation.