The Arc of Somerset County 141 So. Main Street Manville, NJ 08835   VOLUNTEER APPLICATION This application is used to determine your availability, interests and skills which will help in matching you to a program or area that will best utilize your generous offer of assistance. Name: Email:
Address:
Phone Numbers
Home:			Work:
Do you prefer to be contacted at home or work? Home Work
Are you at least 21 years of age:
Contact Person in case of emergency
Name:			Relationship:
Phone(Day):			Phone(Eve.):
Please list your current or most recent employer:
Company Name:			Type of business:
Address:
Direct Supervisor:			Phone:
Poistion Held:			Dates:
Please list 2 persons familiar with your volunteer, employment, or educational experience whom we may contact for reference:
1.) Name:			Relationship:
Phone:
2.) Name:			Relationship:
Phone:
Please list days and hours you are available to volunteer:
What type of volunteer work are you interested in doing?
Do you have employment, educational or volunteer experience that you feel may help you to work with persons with developmental disabilities? If so, please list here. Please note that prior experience is not required to volunteer at The Arc.
		Name of Program/ School/Organization	Dates Involved	Duties:
1.)
2.)
3.)
Do you have any health condition or physical disability that should be considered with regard to your volunteer placement? No Yes
(if yes, please explain):
Do you have any physical limitation that may prohibit you from working with persons who use wheelchairs? No Yes
(if yes, please explain):
Have you ever been convicted of a violation of the law other than a parking offense? No Yes
(if yes, please explain):

I certify that all statements made on this application are complete and accurate to the best of may knowledge. You have my permission to verify this information, to contact references, and to perform a criminal background check. I agree to hold harmless The Arc of Somerset County and its staff while performing volunteer services.

I have read and understand the above and

The mission of The Arc of Somerset County is to provide advocacy and services for all persons with developmental disabilities and their families; to promote their general welfare; to offer opportunities that will maximize their potential to make meaningful choices in the mainstream of society; and to provide preventive and educational services to the community at large.

If you have questions regarding this application, you may contact the Arc Offices at 908-725-8544