Southwest Volunteer Application Form

* required information
Volunteer Application Form 
Contact Information
Please complete this form if you are interested in volunteer opportunities with Canine Companions for Independence. PLEASE NOTE THAT WE CAN ONLY ACCEPT APPLICANTS WHO ARE OVER THE AGE OF 16. On a PC, hold down the control key to make multiple selections. On a Mac, hold down the command key to make multiple selections.
First Name:*
Middle Initial:
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
County:*
Phone:*
Business Phone:
Cell Phone:
Do not email
Do not direct mail
Gender: Female   Male  
Who should we contact in case of emergency?:*
What is your emergency contact's relation to you?:*
Emergency contact's phone number:*
How did you learn about CCI?:
Additional Information
Are you 18 years or older?:* yes
no
Which volunteer opportunities interest you?:*
Preferred days of the week:*
During which hours are you available for volunteer assignments?:* Weekday mornings
Weekday afternoons
Weekday evenings
Weekend mornings
Weekend afternoons
Weekend evenings
Special Skills or Qualifications:
Have you ever been convicted of a crime?:* Yes
No
Please describe the incident:
Incident City/State:
Date of conviction:(mm/dd/yyyy)
Thank you for taking the time to fill out this form. The Volunteer Coordinator will contact you about the next volunteer orientation.
        
Copyright © 2013 Canine Companions for Independence, Inc. All rights reserved.