Volunteer/Intern
Application
Date:
Personal Information
Name: Phone
#
Home Address:
City: State: Zip Code:
Are you: ¨ Student ¨ Homemaker ¨ Retired
Student:
(Name of School) (Major) (Grade
Level)
I want to volunteer because:
I volunteer(ed) for other organizations (ie, church, school, or other service agency)
1.
2.
3.
4.
How many times per month would you be able to volunteer your time?
¨ One day per week ¨
Two days per week ¨ Twice a month
What day of the week would be convenient for you?
¨ Monday ¨ Tuesday ¨ Wednesday ¨ Thursday ¨ Friday
What time of day would be convenient for you? ¨
Mornings ¨
Afternoons
References (please include name, address & phone number)
1.
2.
3.
Phone 815/332-6800 Voice,
815/332-6820 TTY
815/332-6810 FAX
The Center for Sight &
Hearing is an Equal Opportunity Employer