VOLUNTEER APPLICATION FORMPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Today's Date *Name *FirstMiddleLastNicknameAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell PhoneEmail *Date of Birth (optional)Gender (optional)AgeUnder 18*18-2930-3940-4950-5960-6970-7980+*If you are under 18, your parent/legal guardian will need to complete a separate consent form prior to first assignment. If you are 16 or under, you will need to have a parent/legal guardian with you at your volunteer assignments.OccupationHave you ever been convicted of a felony or of any misdemeanor involving theft, dishonesty or moral turpitude?YesNoIf “Yes”, give date and offense:Prior Volunteer Experience [organization(s) and # of years]:How did you hear about Malachi House?Are there any physical restrictions that would affect your volunteer duties (such as lifting, etc.)?YesNoIf “yes”, give details:Special skills/talents you have that may be used in volunteering:Have you had a significant loss in the last year either through death or divorce?YesNoIf “yes”, when? Have you addressed the loss? Emergency Contact Name *RelationshipPhone HomePhone CellPhone Work Reference 1 Malachi House requires two references from volunteer candidates. Please provide the names and full addresses of two people we may contact regarding you; we will send them a form to complete and return directly to us. We ask that the people listed are not family members or personal friends; we’d rather they be someone you have worked with or for, or someone from an agency with which you volunteer or have volunteered. Please print. NamePhoneRelationship to YouEmail *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Reference 2 NamePhoneRelationship to YouEmail *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMALACHI HOUSE Attn: Martha Cromleigh, Volunteer Coordinator 2810 Clinton Avenue Cleveland, OH 44113 (216) 621-8831 (216) 621-8841 (fax) Submit If you are having any problems with the online form you can click below and print out the PDF Version – CLICK HERE
