Please complete the following
application online. (If you prefer, you may download
the application and mail it in.)
I. Personal Information
*First Name:
*Last Name:
*Street Address:
*City:
If Philadephia, which part of the city do you live in ?
*State:
*ZIP code:
Home Phone:
Work Phone:
Cell Phone:
*Email:
What is the best time to reach you?
*What is the best way to reach
you?
Please select
Home Phone
Work Phone
Cell Phone
Email
Marital Status:
Work:
Date of Birth:
example: 01/01/1965
Emergency Contact Information:
Highest Level of Education Attained:
*Do you have any health concerns/limitations
that Penn’s
Village should be aware of?
Please explain:
What special talents, expertise and/or
interests do you bring to Penn’s Village?
*Have you ever been convicted
of, pleaded guilty to, or entered a plea of no contest or
no lo contender to any crime other than a summary offence
or a summary motor vehicle violation?
Note: Criminal History will not automatically result in denial or loss of volunteer
placement.
Please explain:
II. Personal Preferences
Please choose the areas of
interest to you:
III. Employment Information
Most recent employer:
Position title:
Name & title of last supervisor:
Address:
Phone:
Brief description of duties:
Previous employer:
Position title:
Name & title of last supervisor:
Address:
Phone:
Brief description of duties:
IV. Volunteer Experience
Volunteer Experience:
Name & title of last supervisor:
Address:
Brief description of duties:
Volunteer Experience:
Name & title of last supervisor:
Address:
Brief description of duties:
V. References
*Reference #1 Name:
*Address:
*Phone:
Reference #2 Name:
Address:
Phone:
I understand that Penn’s Village members
are depending on me and that they deserve to be treated with
kindness and dignity. If I am unable to fulfill a commitment
I have made to provide a service for a member, it is my responsibility
to notify Penn’s Village in sufficient time for a replacement
to be identified. I will honor the confidentiality of the members
that I serve and all of Penn’s Village rules and regulations.
I certify that the above information is true and correct
to the best of my knowledge. I hereby authorize Penn’s
Village to investigate the information contained in this
application, including making inquiries of law enforcement
agencies for possible pending charges or convictions. I authorize
my employers, educational institutions, law enforcement agencies
and the U.S. Government to release information about me to
the Volunteer Department, and agree to hold harmless these
organizations, their officers, directors, employees and agents
from all liability, claims, damages or demands of any nature
arising from or related to its investigation of information
contained in my application.
