Volunteer Application — Shepherd's Center of Northern Virginia

Matching Information
General interests, skills, volunteer experience, languages, and hobbies:
Screening Information:
Have you ever been convicted for violation of any laws, traffic or otherwise?
- Yes
- No
If yes, please explain:
Please note a criminal record check will be done for prospective volunteers who will work directly with our clients.
Do you have any physical condition that may limit your volunteer activities?
- Yes
- No
If yes, please describe:
Do you have a valid driver’s license?
- Yes
- No
License number:
Expiration Date:
MM slash DD slash YYYY
Insurance Company:
Policy Number:
Expiration Date:
MM slash DD slash YYYY
Emergency Contact
Emergency Contact Name:
Phone:
Relation:
Emergency Contact Address
Street Address Address Line 2 City ZIP / Postal Code
State*
References
Please list two people we may contact who are not family members. (You may include employers, teachers, religious leaders, etc.)
Reference #1 Name:
Phone:
Relation:
Reference #1 Address
Street Address Address Line 2 City ZIP / Postal Code
State*
Reference #2 Name:
Phone:
Relation:
Reference #2 Address
Street Address Address Line 2 City ZIP / Postal Code
State*
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Name
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