Confidential Volunteer Application

Date:___________________
Personal Information
Last Name:_____________________________ First Name:_____________________________
Address:_____________________________________________________ Apt#:____________
City:_________________________________________ State:__________ Zip:_____________
Phone: (C)_______________________________ (H)___________________________________
(W)______________________________ May we contact you at work? Yes____ No____
Email:__________________________________________
Volunteers and/or Interns working directly with our clients must be at least 21 years of age.
Male____ Female____

Date of Birth:_______________________

Statistical Information *For internal statistical purposes only

All volunteers will be considered impartially and without bias of race, religion, sex, age, national
origin, physical ability, or sexual orientation.
*Marital Status:
*Education:

Single____ Married____
High School____ Some College____ GED____
Undergraduate Degree____ Graduate Degree____ Other____
Major and Degree_____________________________________________

*Primary Language: English____ Spanish____ Signing____ Other____

*Secondary Language: English____ Spanish____ Signing____ Other____
*Race/Ethnicity:
African American____ Asian American____ Caucasian____ Latino____
Native American____ Pacific Islander____ Multi-ethnic____ Other____

Areas of Interest
Please check all that apply.
Administration
Events
Fundraising
Grant writing
IT support

Arts/crafts
Music
Sports/recreation
Tutor

Landscaping
Facilities/maintenance
Professional (medical, legal)
Other:________________

Please provide a description of the services you would like to provide to Streetlight USA:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Employment and/or Education
Employment Status: Full time____ Part Time____ Not Employed____ Retired____
Name of Employer:______________________________________________________________
Position and Job Description: ______________________________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If a student, name of school:______________________________________________________
Brief description of additional work experience/history:_________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Volunteer Experience
List Volunteer Experiences:

Organization

City/State

Position

Dates of Service

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Current community activities, memberships, etc.:____________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Brief description of hobbies, interests, skills, and areas of training/expertise:______________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Have you applied for a job or volunteered with Streetlight USA in the past? Yes____ No____
If Yes, please describe:___________________________________________________________

___________________________________________________________________
___________________________________________________________________
Availability
Date available to begin volunteering/interning:_______________________________________
Mornings____ Afternoons____ Evenings_____ Weekdays____ Weekends_____

Referral
Referred by: Flyer____ Friend____ Internet____ Colleague____ School____

Other_____________________
Criminal History
Have you ever been arrested or convicted of a crime (including a DUI)? Yes____ No____
If yes, please describe:___________________________________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Have you ever been convicted of neglect, abuse or substance dependency? Yes____ No____
If yes, please describe:__________________________________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Do you have a valid drivers license? Yes____ No____

License #:_____________________
Expiration Date:________________

Has your drivers license ever been suspended or revoked? Yes____ No____
If yes, please describe:____________________________________________________
______________________________________________________________________
Do you currently hold a Department of Public Safety fingerprint clearance card? Yes___ No___
Card #:__________________________________________ Expiration Date:_______________

References
List three (3) personal references. If you are employed, one reference should be from your
employer. Please do not list relatives or anyone living in the same household.

Name:__________________________________

Relationship:_________________________

Daytime Phone:__________________________

Email:______________________________

Name:__________________________________

Relationship:_________________________

Daytime Phone:__________________________

Email:______________________________

Name:__________________________________

Relationship:_________________________

Daytime Phone:__________________________

Email:______________________________

I, _________________________________________, hereby affirm that all of the answers

provided on my application are true. I understand that misrepresentations or omission of facts
called for is cause for dismissal. I hereby authorize Streetlight USA to investigate my
background and to contact the above given references for the purposes of determining my
suitability as a potential volunteer/intern.

Signature:_____________________________________________ Date:__________________
Please submit your completed application to:
Streetlight USA
Volunteer Services
PO Box 6178
Peoria, AZ 85381
Fax: (623)435-0910