Volunteer Services > Volunteer Application

Date:

Name:

Mailing Address:

Is this address: home

business

temporary

seasonal

Day Phone #

Evening Phone #

Cell Phone

E-mail Address:

DOB:

Employer (or School):

Referred by/learned about Crotched Mountain through:

Family Physician:

Phone:

Emergency Contact:		Relationship:
Home Phone:		Work Phone:		Cell Phone:

Hobbies Skills and Interests: (50 Characters Maximum) *

What is your prior volunteer experience: (50 Characters Maximum)*

What days, times, and how often do you wish to volunteer? (50 Characters Maximum) *

* To include further information or a resume, send an email to: Kevin.Harte@crotchedmountain.org

Please give a reference:

Name:

Phone:

Name:

Phone:

BACKGROUND CHECK: As part of the application process, we require that you sign and have notarized a CRIMINAL RECORD RELEASE AUTHORIZATION FORM. We will use this release form to obtain from the appropriate State organization a record of any criminal convictions that you may have. This background check is required of us by the rules and regulations of the State of New Hampshire, Department of Health and Human Services.

PLEASE READ

You will be asked to sign this form

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND HEREBY GRANT THE FOUNDATION PERMISSION TO VERIFY SUCH ANSWERS. I HEREBY AUTHORIZE THE RELEASE OF ANY RELEVANT INFORMATION FROM ANY APPROPRIATE SOURCE.

Signature: ___________________________________________ Date: __________