Peter & Paul Community Services

Volunteer Application- Please Print Legibly

Name: ______

Name of Group Coordinator: ______

School/ Business/ Group Name: ______

Scheduled Volunteer Date (if previously scheduled): ______

I want to/will volunteer at (please circle): Shelter Meals Program Garfield Other: ______

Personal Information:

Address: ______

City:______State:______Zip:______

Telephone Number: ______

E-Mail Address: ______

In Case of Emergency, please notify (name & phone): ______

Current or Previous Employer (company name & title): ______

Community Organization / Church Membership: ______

* Please add me to the mailing list: Yes ______No ______

(Your information will be used only for Peter & Paul Community Services)

Availability

I am available between (start date) ______and (end date) ______

I would like to volunteer ______hours per ______(week/month)

I am available to volunteer (draw an X in the applicable boxes)

Saturday / Sunday / Monday / Tuesday / Wednesday / Thursday / Friday
9am-11:30am
11:30am-3pm
3pm- 6pm
6pm-8:30 pm

Waiver/Release:

I hereby agree to indemnify, defend, and hold harmless Peter & Paul Community Services, Inc and its employees, agents, servants, officers, trustees and representatives (in their individual and official capacities) from any and all liability, loss or damages they or any of them incur or sustain as a result of any claims, demands, damages, actions, causes of action, judgments, costs or expenses including attorneys’ fees, which result from, arise out of, or relate to my participation in, or travel to and from, and in conjunction with Peter & Paul Community Services, Inc and its programs.

Confidentiality Form:

This confidentiality form serves as an agreement between ______

and Peter & Paul Community Services, that all files, charts and personal information on our clients is considered personal and confidential material. Client information is not to be released or viewed under any circumstance, by anyone other than a PPCS staff members, or other allowed parties.

I, ______, understand that all client information is considered confidential and should not be viewed. I also understand that I may be terminated if I do not abide by the confidentiality agreement stated above.

Signature: ______Date: ______

If Under 18, Guardian’s Signature: ______Date: ______

CONSENT TO BE PHOTOGRAPHED

Name ______

I hereby authorize Peter & Paul Community Services, Inc., or its representative, to take photographs of me in whole, or in part, to develop and print said photographs and to publish or display them for any reasonable purpose, which in the sole discretion of Peter & Paul Community Services, Inc., it considers proper.

I hereby evidence my voluntary consent to all of the foregoing by execution of this document.

I hereby waive any right that I may have to inspect and/or approve the photographs that may be used, or the specific use to which they may be applied.

I further agree not to hold Peter & Paul Community Services, Inc., its personnel or representatives responsible for any liability which may result from this permission, and agree not to assert any claims or demands resulting from the taking and/or use of such photographs.

If individual is under the age of 18 years, parental permission is required.

______

Signature Parent’s Signature

______Date Date

For more information, please contact Meghann Van Pelt, Volunteer Coordinator

Tel.: 314-338-8191 ● Fax: 314-621-9875 ● Email: ● Web: www.ppcsinc.org

Peter & Paul Community Services, Inc. ● 2612 Wyoming, St. Louis, MO 63118