AMERICAN RED CROSS VOLUNTEER APPLICATION FORM
(The use of this form does not necessarily indicate that positions are open.)

 

Last Name                                                                 First                                                           Middle                                      

 

Home Address                                                          City                                         State                         Zip code

 

Business Address                                                     City                                         State                         Zip code

 

Home Phone                               Business Phone                                             E-Mail Address                        Fax Number

 

 

Experience: (Include both paid and volunteer work experience, beginning with most recent)

 

Organization Name

 

 

Address

 

Phone

 

From ____________To ______________

 

Supervisor’s Name/Title

 

 

Organization Name

 

Address

 

Phone

 

 

From ___________  To _____________

 

Supervisor’s Name/Title

 

Organization Name

 

 

Address

 

Phone

 

From ___________   To _____________

 

Supervisor’s Name/Title

 

Current License(s)

 

Type:

 

Number:

 

State:

 

Expiration Date:

 

Type:

 

Number:

 

State:

 

Expiration Date:

 

Education and Training (begin with most recent)

 

Institution Name

 

City/State

 

Degree/Major

 

Date Attended

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fluent Language Skills (include sign language)

 

 

 

Volunteer Opportunities: Check Activities Which Interest You or Skills You Possess (Must be at least 15 years old to volunteer unless otherwise specified)

 

o Bloodmobile                                           o     Blood Service Delivery                                 o Office Volunteer

o Blood Pressure Screening                      o   Disaster Services                                           o Youth Programs   

o CPR/First Aid Instructor                       o    Special Events/Projects                     

o HIV/AIDS Education                               o   AFES/Service to Military

o Other:__________________________

                                                                                                                                                SEE SIDE 2



 


 

 

Availability:

 

   o Monday              o Tuesday         o Wednesday       o Thursday            o  Friday              o  Saturday           o Sunday Morning/Afternoon/Evening  Morning/Afternoon/Evening   Morning/Afternoon/Evening   Morning/Afternoon/Evening    Morning/Afternoon/Evening     Morning/Afternoon/Evening    Morning/Afternoon/Evening

 

Are you available for a short-term project?

 

Yes

 

No

 

Emergency Contact Information:

 

Name                                              Relationship                                Address                                                        Phone

 

Previous Red Cross Experience:

 

Have you ever worked as a Red Cross employee?  If Yes, Give Position, Dates, and Location.

 

 

Yes

 

No

 

 

 

Have you ever worked as a Red Cross volunteer?

 

Yes

 

No

 

Have you ever held any Red Cross certification (e.g., Health & Safety instructor, DSHR member)?  If yes, please list.

 

 

Yes

 

No

 

 

 

      A “yes” answer to the following italicized questions will not necessarily disqualify any applicant.

 

Are you licensed to operate a motor vehicle in this state?

 

Yes

 

No

 

Has your license to operate a motor vehicle ever been revoked?  If yes, please explain.

                                                                                                                                                                                                                             

 

Yes

 

No

 

 

 

Have you ever been bonded?

 

Yes

 

No

 

Has your bonding ever been revoked?  If yes, please explain.

 

 

Yes

 

No

 

 

 

Have you ever been convicted of a felony, or within the past 24 months, of a misdemeanor that resulted in imprisonment?  If yes, please explain.

 

 

Yes

 

No

 

 

 

Have any of your Red Cross certification ever been revoked?  If yes, please explain.

 

 

Yes

 

No

 

 

 

Why do you wish to volunteer with the American Red Cross (optional):

 

 

VOLUNTEER CONSENT FOR REFERENCE AND BACKGROUND CHECKS

 

I do hereby give the American Red Cross permission to inquire into my educational background, references, driving record, police records, employment, and/or volunteer history.  I further give permission to the holder of any such records to release the same to the American Red Cross.   I do hereby hold the American Red Cross harmless from any liability, whether civil or criminal that may arise as a result of the release of this information about me.  I further hold harmless any individual, agency, business, or corporation that provides information or documents to the above-named American Red Cross unit. I understand that the American Red Cross will use this information as part of its verification of my volunteer application and periodically for evaluation purposes.

 

 

Name-Please Print              

 

__________________________________________                                                                                                                   ________________________________

Signature                                                                                                                                                                                                         Date

 

__________________________________________                                                                                                                   ________________________________

Witness                                                                                                                                                                                                            Date