| Name: | |||||||||
| Street: | |||||||||
| City: | State: | Zip: | |||||||
| Home Telephone: | Email: | ||||||||
| Current Employer: | |||||||||
| Employer Address: | |||||||||
| May we call you at work? | Work Telephone: | ||||||||
| Education (if presently enrolled, give classification and major): | |||||||||
| In emergency Call: | Telephone: | ||||||||
| Relationship: | |||||||||
| How did you learn about M.A.S.H. Services of the Bluegrass? | |||||||||
| What is your background in working with youth? | |||||||||
| Volunteer Opportunities | |||||||||
| Please check the opportunities you're interested in. | |||||||||
|
Youth Outreach | |
Student Practicum | ||||||
|
Mentoring | |
Business Area | ||||||
|
Maintenance | |
Recreational Activities | ||||||
|
Other | ||||||||
PAGE 2
| Please write a short essay on why you want to volunteer or do intern work at | ||||||||
| M.A.S.H. Services of the Bluegrass . Inc. | ||||||||
| Hours and days you are available: | ||||||||
| Monday: | Friday: | |||||||
| Tuesday: | Saturday: | |||||||
| Wednesday: | Sunday: | |||||||
| Thursday: | ||||||||
PAGE 3
| Please list three people whom you have known for at least one year and who | ||||||||
| can attest to your character, skills and dependability. Do not include | ||||||||
| relatives. | ||||||||
| Name: | ||||||||
| Address: | ||||||||
| Telephone: | ||||||||
| Relationship: | ||||||||
| Name: | ||||||||
| Address: | ||||||||
| Telephone: | ||||||||
| Relationship: | ||||||||
| Name: | ||||||||
| Address: | ||||||||
| Telephone: | ||||||||
| Relationship: | ||||||||
| PLEDGE OF CONFIDENTIALITY | ||||||||
| I understand that in the course of my work for M.A.S.H. Services of the Bluegrass | ||||||||
| I may learn facts about residents, volunteers, and employees of M.A.S.H. Services | ||||||||
| of the Bluegrass that are of a highly personal and confidential nature. I understand that | ||||||||
| all such information is completely confidential. I agree not to disclose any infor- | ||||||||
| mation of a personal nature to any person. If my volunteer work involves working | ||||||||
| directly with residents, I will learn in training and/or supervision what information | ||||||||
| about residents I should report and to whom I should report such information. | ||||||||
| In case of doubt regarding a situation, I will first contact that staff person | ||||||||
| to whom I report. | ||||||||
| Signature: | Date: | |||||||