INTERLINK, INC.

EVERYDAY HEROES FACE TO FACE

817A 6^th Street, Clarkston WA 99403-2002

interlink@clearwire.net

509-751-9143  FAX 509-751-9819

VOLUNTEER APPLICATION

(Please Print)

 Full Name                                                                                                                                                             

Social Security Number                    -             -                       Sex: F            M                 Birthdate           /            / _____

Home Address ______________________________________________________________________________

Phone ___________________E-mail Address                                                                                                            

May we contact you at work for requests?  Yes              No                            Work Phone                                                          

In case of emergency, please contact                                                                                                                                                  

Relation to you                                                                  Home No.                                             Work No.                                      

Church Affiliation (if any)                                                                                                                               

 Skills I am willing to share:                                                                                              

      Local Transportation                                           Housekeeping                                __ Home Repair

      Long-distance Transports                                  Yard Work                                             Plumbing

      Shopping                                                               Moving                                                  Electrical                         

      Friendly Visitor                                                     Wash windows                                    Carpentry                       

Other (Explain)                                                                                                                                                                                     

Committees I am willing to work on:               

      Volunteer Appreciation                                      Fund Raising                                        Board Member

      Volunteer Recruitment                                  ___ Public Relations

Special Training / Schooling / Languages                                                                                                                                               

Special Interests, Skills or Hobbies                                                                                                                                                           

Who or what prompted you to volunteer?                                                                                                                                               

 References:  Name                                                    Relationship                                          Phone No.                                        

                      Name                                                     Relationship                                          Phone No.                                        

Would you prefer working with:            Man                  Woman                      Child                      All                        

Have you had CPR training within the last year?      Yes             No ______

Do you own a car?          truck?             Do you carry insurance on your vehicle? Yes             No ______

            Idaho State, or Washington State, Driver’s License Number                                                                      

(Attach a photocopy of your CURRENT proof of auto insurance and drivers’ license when returning this form.)

Do you agree to submit to a background check?  Yes             No ______

Have you ever had a police record? Yes             No ______       

List your availability or preferences (example: No Monday mornings, etc.)                                                                                                                                                                                                                                 

Any health limitations, allergies or other concerns, we should be aware of?                                                                                                                                                                                                                                  

a  INTERLINK VOLUNTEER AGREEMENT  a

INTERLINK is dependent upon a climate of mutual caring and trust between volunteers and the recipients they serve. When a person seeks assistance through the program, personal information is shared, such as income, medical problems, and age. As volunteers work with recipients, they observe lifestyles, belongings, and family situations. All recipient information will be kept confidential.

INTERLINK volunteers will receive an initial orientation.

INTERLINK offers volunteer liability insurance coverage for all volunteers. Any volunteer who provides escorted transportation to Interlink recipients, will be required to provide the office with proof of current vehicle insurance coverage, and a valid drivers license.

Mileage reimbursement is available for all volunteers. An original signature of the volunteer is required on the provided mileage voucher. Volunteers are requested to record and report all activities to the office staff by the 5^th day of the month following the activity.

INTERLINK reserves the right to refuse any application on any basis deemed reasonable.

All information provided to INTERLINK on this form, is confidential.

...................................

I understand the need for INTERLINK in the valley and that my volunteer assignment is an important faith commitment. I will make every attempt to live up to the responsibility.

I understand the importance of accurate record keeping for the welfare of both the recipient and INTERLINK.

I agree to observe and fulfill the above statements.

                                                                                                                                _____ / _____ / _____

                                                                              VOLUNTEER                                       DATE

            References checked by:                                                                               _____ / _____ / _____

                                                                                  STAFF                                              DATE

(Please remember to include the copy of your current auto insurance coverage, and valid drivers license with this signed form. Thank you.)