Volunteer Application Form

Name

First Last

Today’s Date

Phone - Home

Phone - Mobile

Address

Street Address Address Line 2 City State ZIP Code

Requested Location

Requested Service Area

Have you ever been employed by the Head Start program?

Yes
No

City and State

High School

Date of Graduation

College

City and State

Level Completed

Date of Graduation

Vocational/Technical School

Certificate

Date of Graduation

Other

Do you have any physical limitations which would give you problems in performing classroom activities with preschool children or performing light janitorial duties?

Yes
No

If yes, please explain:

Would you take a physical examination if required?

Yes
No

Do you have documentation of an annual TB skin test?

Yes
No

If no, you must obtain the TB skin test before you can volunteer regularly in a Head Start Site.

Are you willing to take a drug test?

Yes
No

References

Name

First Last

Address

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

Phone

Name

First Last

Address

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

Phone

Name

First Last

Address

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

Phone

Has a court ever denied parental custodial or visitation rights to you as a result of child maltreatment?

Yes
No

If yes, please explain:

Have you ever been convicted of or pleaded guilty to or plead nolo contendere to a felony or misdemeanor in the following categories – Please check yes or no by the following that applies:

Violence

Yes
No

Child Abuse

Yes
No

Child Neglect

Yes
No

Any other felony or misdemeanor involving violence or sexual misconduct:

Yes
No

If yes, please explain:

In Case Of An Emergency, Please Notify:

Name

First Last

Phone

Address

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

Relationship

Name

First Last

Phone

Address

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

Relationship

Thank you for filling out this form so we can get to know you better! If you have any questions, please contact us at (501)570-5000.

Name

This field is for validation purposes and should be left unchanged.

Volunteer Application Form