Last Name ________________________________________First Name _________________________________Middle Initial____

Address__________________________________City______________________State______________ZIP______________

Social Security No,. __________________________________________ Birth Date ______________________________________

How did you find out about our volunteer opportunities? _____________________________________________________________

Through my involvement with CMHS, I hope to: ____________________________________________________________________

I would like to volunteer to: _____________________________________________________________________________________

I am willing to work up to ___________________ hours per week during these times:

_____ Weekday Mornings _____ Weekday Afternoons _____ Weekday Evenings _____ Weekends

What time commitment do you desire? _____ 1-3 Months _____ 3-6 Months _____ 6-12 Months

I am most interested in an _____ Ongoing assignment _____ Occasional volunteer assignment

Transportation: _____ Have the use of a car _____ Rely on others _____ Walking distances only

Please list previous experiences (volunteer, paid or educational) that you would like to use in a volunteer position:

Activity Organization Date

____________________________________________________________________________________________________________Activity Organization Date

Activity Organization Date

____________________________________________________________________________________________________________Activity Organization Date

I understand that I may come into contact with patients and/or their records and that these are to be held in strictest confidence.

Volunteers are a vital part of Comprehensive Mental Health Services, Inc.’s mission. In order for our work to continue successfully, we ask that you give any volunteer assignment the same careful, conscientious effort you would to a paid position. I understand that the above information is voluntarily supplied and may be disclosed for Comprehensive Mental Health Services’ purposes and that as a CMHS volunteer, I will not be paid for my services. I also understand that I may be required to sign a Release and Waiver of Liability

Before I can begin volunteering.

Signature _______________________________________________________________ Date ______________________________

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