Volunteer Application Application to submit if interested in volunteering Date* Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Phone (home)*Phone (cell)*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Occupation*Is your work*Full TimePart TimeBusiness/School NamePhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about Heights and Hills?Why do you want to volunteer with Heights and Hills?Please describe your previous volunteer experience:What special skills, interests, foreign language, and/or life experiences would you like to share?What days are you available?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Choose all that applyWhat times are you available?*What kind of volunteer services would you like to perform?* Shopping Squad (occasional grocery shopping for home-bound older adults) Friendly Visiting (bi-weekly phone calls to foster new friendships with socially isolated older adults) Wellness calls (weekly calls to home-bound older people to check on food and medication needs) Other Check all those that applyOtherSpecifyPlease provide TWO REFERENCES (no relatives, at least one previous or current work/volunteer supervisor)1. Name*Address*Phone*Email*How does this person know you?*2. Name*Address*Phone*Email*How does this person know you?*Have you ever been convicted of a criminal offense?YesNoIf yes, please explainMay we use your name in our publications?YesNoMay we use your photo in our publications?YesNoEMERGENCY CONTACT INFORMATION:Emergency Contact NameEmergency Contact NumberRelationship to you:Please indicate whether or not you are fulfilling hours for school requirementYesNoIf yes, how many hours do you need to complete?By what date do your hours need to be completed by?I affirm that the information on this applications is correct. I am aware that a criminal background check will be performed upon submittal of this application.Signature*DateSubmitted application will be sent to our Volunteer Program staff who will follow-up with you based on your interests.