Name
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First Name
Last Name
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone
(###)
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Secondary Phone
(###)
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Are you a Medical Professional? Identify your credentials:
Medical Affiliation Group, if any:
Educational Background (highest degree attained)
If you are currently enrolled in school, name of school:
Academic Year:
Employment Background, Employer 1:
Position:
Primary Responsibilities:
Work Phone:
(###)
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Length of Time:
Employment Background, Employer 2:
Position:
Primary Responsibilities:
Work Phone:
(###)
###
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Length of Time:
Skills: Do you speak a language other than English? If so, please list:
How did you hear about Fresh Start Caring For Kids Foundation?
Please describe how we could best use your skills and talents to form an enriching and lasting volunteer relationship:
Please mark your area(s) of qualification(s). Check all that apply.
If 'Other', please indicate:
Health Background: Are there any health-related issues that may limit your ability to volunteer?
If yes, please describe:
Electronic Signature: By checking 'yes' below I certify that all information stated in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration as a volunteer and may result in my immediate dismissal if discovered at a later date. I authorize and release personal references, employers (past and present), and if necessary, otehr applicable entities to answer questions in regards to my volunteer work, employment, ability, character, medical and emotional background and, if applicable, driving history.
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Type Full Name:
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Date
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MM
DD
YYYY