Enter Name

Street Address

City, State, Zip

Home Phone

Cell Phone

Work Phone


Emergency Contact

Emergency Contact Phone Number

Are you a U.S Citizen?

Are you 18 years of age?

Date of Birth

Are you affiliated with a church?

If yes, what church?

During which hours are you available to volunteer?

Tell us in which areas you are interested in volunteering: (Persons who volunteer at our
Donation Center are not eligible to receive free goods through our Samaritan Center or by
any other means.

Administrative/ClericalBible StudyDonation Center"Feed My Sheep" Dining RoomHidden Treasures Thrift StoreInstructor/TeacherResident Support Staff Asst.Samaritan CenterSpecial EventsSpecial ProjectsTelephone CallsVolunteer DriversYouth Volunteer

Please state any qualifications and/or special skills that you have which will help demonstrate your ability to assist in the interest areas that you checked above.

Have you ever been a resident of the City Mission? (Former residents must complete the "Former Resident Agreement" as part of the application process)

If yes, when? (List dates)

Do your hours need to be tracked for Community Service?
If yes, please explain and list total hours needed.

Please list four references (please use one professional reference. Community Service applicants MUST use their Community Service contact as a reference. NO RELATIVES)

Reference One

Reference Two

Reference Three

Reference Four

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I acknowledge that I am volunteering my services freely without any understanding or promise of reward or compensation for my services.

As part of my City Mission volunteer service, confidential information may be disclosed to me. I agree that whenever that is done, I will respect the confidentiality of that information. I also acknowledge that upon accepting this agreement that I permit the City Mission to perform any necessary background and reference checks.