VOLUNTEER APPLICATION
LIFE Center for Independent Living

Date: ____________________

Name: ___________________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Telephone: (     ) __________    (Circle or highlight one)     Voice     TTY     FAX

E-Mail: __________________________________________________________


Please check or highlight the subjects and volunteer jobs that interest you:

Advocacy

_____ Advocacy action group
_____ Housing, accessible
_____ Built environment accessibility
_____ Legislative advocacy
_____ Education rights
_____ Mental health issues
_____ Health care
_____ Transportation
_____ Other __________________________________________________

Helping the Center

_____ Answering the telephone
_____ Painting
_____ Clerical work
_____ Planning special events
_____ Data entry
_____ Preparing large mailings
_____ Database development
_____ Reader
_____ Driver for staff
_____ Receptionist substitute
_____ Fund raising
_____ Storage management
_____ Light maintenance work
_____ Support group facilitator
_____ Make telephone calls
_____ Word processing
_____ Other __________________________________________________


What do you hope to gain and to give as a volunteer? ___________________
_________________________________________________________________
_________________________________________________________________


How many hours each week or month do you wish to volunteer?      Week _____ Month _____

Indicate what days and hours you are available to volunteer.

_____ Monday            Times ______________________________________
_____ Tuesday           Times ______________________________________
_____ Wednesday     Times ______________________________________
_____ Thursday          Times ______________________________________
_____ Friday               Times ______________________________________
_____ Saturday          Times ______________________________________
_____ Sunday             Times ______________________________________


PERSONAL REFERENCES
If your volunteer work involves working one-on-one with individuals with disabilities, we must check your references and request a criminal background check from the Illinois State Police, as we do for staff. This is done to comply with state law and for the safety of our consumers. Your Social Security Number is needed for the criminal background check.

Reference Name: __________________________________________________

Reference's daytime phone: ________________________  Voice   TTY   FAX

Reference Name: __________________________________________________

Reference's daytime phone: ________________________  Voice   TTY   FAX

Your Social Security number: ______ / ____ / ________