Volunteer Guardianship Application

"*" indicates required fields

GENERAL INFORMATION

Name*

Maiden Name or Nickname

Date of Birth*

Social Security Number

Email*

Home Phone

Cell Phone

Business Phone

ADDRESS

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Length of time at current residence:*

Marital Status*

Spouse's Name

Occupation*

Spouse's Occupation

Tell us about your children:

Name

Age

Gender

What is the highest level of education that you completed?*

Please list any colleges, degrees held, continuing education, special training, etc.:*

Do you speak a foreign language?*

Yes

Can you communicate using sign language?*

Yes

Describe any hobbies or special interests you think are relevant.*

EMPLOYMENT HISTORY

CURRENT EMPLOYMENT

Employer*

Phone*

Employed From:*

Employed To:

ADDRESS

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Describe your position and your responsibilities.*

PREVIOUS EMPLOYMENT

EMPLOYER 1

Employer*

Phone

Employed From:*

Employed To:*

ADDRESS

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Describe your position and your responsibilities.*

EMPLOYER 2

Employer

Phone

Employed From:

Employed To:

ADDRESS

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Describe your position and your responsibilities.

EMPLOYER 3

Employer

Phone

Employed From:

Employed To:

ADDRESS

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Describe your position and your responsibilities.

Have you ever been fired, terminated, or disciplined from employment?*

Yes

PERSONAL REFERENCES

Please provide us with three references (over the age of 18 years old). At least two of the references should be business, professional, or clergy (non-family members, please). Please notify your references so that they will expect our communication with them.

References*

Name

Relationship

Phone

Address

VOLUNTEER EXPERIENCE

Have you ever been appointed as guardian in the past for anyone?*

Yes

Describe any specific skills and/or personal qualities you feel would be helpful to you as a volunteer guardian.*

Why are you interested in volunteering to become a guardian in our program?

Please list any professional, personal, and/or volunteer experiences working with the elderly, the mentally ill, or the mentally disabled:*

Please list any other volunteer experiences, if any:

How did you hear about the Volunteer Guardianship Program?*

Do you have any physical or mental conditions that may limit your ability to serve as a volunteer guardian? If yes, please explain.*

EMERGENCY CONTACT

In an emergency, please contact:

Name*

Relationship*

Home Phone

Cell Phone*

Work Phone

ADDRESS

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code