Street Address

City ST Zip Code

Home Phone

Occupation

Name of Employer

Work Address

Work Email

Work Telephone

Cell Phone

Fax Number

Email Address

Please note if phone number is an unlisted number (check one):

Yes
No

Additional Information

Are you between the ages of 14 – 18? (check one):

yes
no

If you are a student, what school do you attend:

School

Grade

If you have a child, please list the name of their school & the school district they belong to:

School

Grade

How did you hear about Discovery Center?

Previous Work Experience

Summarize your previous work experience.

Previous Volunteer Experience

Summarize your previous volunteer experience.

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including computer/software skills and foreign language skills.

Are you a person with a disability? (check one):

yes
no

If so, what special accommodations are needed to assist you? (please list )

Interests

Tell us in which areas you are interested in volunteering – Check all that apply

Other:

Availability

During which hours are you available for volunteer assignments?

Check type of assignment willing to work:

Long-term (several weeks/months) Short-term (several days/hours) either

Please note if you are available to work AT HOME ONLY (check one):

yes
no

References

Name Phone

Name Phone

Person to Notify in Case of Emergency

Name Relationship

Street Address

City ST Zip Code

Day Phone Night Phone

Related Background Information

Have you ever been convicted of or pleaded “no contest” to a crime in the past 10 years which has not been

annulled, expunged or sealed by court? (check one):

yes
no

If yes, please explain:

Have you ever been charged with sexual misconduct, child molestation or child abuse? (check one):

yes
no

If yes, please explain:

Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentationsmade by me on this application or any inappropriate action in the future that reflects adversely on theDiscovery Center will result in my services no longer being utilized as a volunteer.

I hereby give the Discover Center for Science and Technology, its legal representative and assigns, theright and permission to publish, without charge, photographs of me taken at any and all DiscoveryCenter events. These pictures may be used in publications, audiovisual presentations, promotionalliterature, advertising, calendars, or in any other matter. I hereby warrant that I am over 18 years ofage, and am competent to contract in my own name insofar as the above concerned.

Name Date

For applications submitted electronically (via email), checking the box to the right will be deemed your signature and acceptance of the terms of this agreement.

Our Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. We reserve the right to place volunteers in the area we feel is best suited for their skills and the needs of the Discovery Center.

Thank you for completing this application form and for your interest in volunteering with us.

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