General Information Name * First Last * Last Middle Initial Middle Initial Birthdate * (MM/DD/YYYY) Gender * Male Female Address * City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip * Day Phone * Other Phone Email * Emergency Contact Person * Contact Phone * When are you available to begin volunteering? * (MM/DD/YYYY) Do you have any medical, physical or mental impairment that may interfere with you ability to complete volunteer tasks? * No Yes Please explain. * Have you ever been convicted of a felony? * No Yes Please explain. * Education (Please note that at least one row of Education information is required.) High School, University and other institutions attended.Begin with most recent. Discipline, Program or Major Degree/Diploma/Certificate Date Obtained orExpected(MM/DD/YYYY) School * Major * Degree * Date School * Major * Degree * Date School * Major * Degree * Date Qualifications Please describe the knowledge, skills, certifications, training and abilities which best describe your qualifications as a Volunteer. * Extracurricular Activities Please highlight any additional volunteer experience, memberships in clubs or organizations, hobbies, etc. * References Name * Address * Contact Number * Name * Address * Contact Number * Name * Address * Contact Number * Volunteer Interests Please check ALL areas in which you have a potential interest in volunteering as an assistant or a facilitator Adaptive Sports Tournaments and Event Assistance Sport Classes and Activities Art Art Studio and Classes Craft Classes Expressive Arts Creative Writing Dance Music Theatre Fitness Fitness Center Class Assistance/Escort Horticulture/ Gardening Member Classes Maintain Butterfly Garden Social Activities Weekly Activities Member Special Events Administrative Reception/ Gallery Assistant Committee Involvement OtherOther The Center for Individuals with Physical Challenges provides an equal opportunity Volunteer Program. We adhere to a policy of selecting Volunteers without regard to race, color, religion, gender, age, marital status, sexual orientation, national origin, political affiliation or disability. Opportunity to Volunteer with The Center depends solely upon an applicant's qualifications. The Center for Individuals with Physical Challenges Attn: Volunteer Program 815 South Utica Avenue Tulsa, OK 74104 Ph: 918-584-8607 Fax: 918-584-8646 www.tulsacenter.org If you are human, leave this field blank.
