Become a Shepherd’s Center Volunteer!

Name

Address

City

Zip Code

Phone (home)

Phone (mobile)

Email Address

Date of Birth

How did you hear about the Shepherd's Center of Greater Tupelo?

Volunteer Interests (check all that apply) Volunteer Interests (check all that apply) Driver Friendly Caller In-home Visitor Handy Helper Fundraising Program Committee Marketing & Publicity Board of Directors Other

Car Size (check all that apply) Car Size (check all that apply) Compact Midsize Full Size SUV Truck Van

Availability Availability Monday Tuesday Wednesday Thursday Friday

Monday Availability (hours available)

Additional Comments regarding your availability on Mondays

Tuesday Availability (hours available)

Additional Comments regarding your availability on Tuesdays

Wednesday Availability (hours available)

Additional Comments regarding your availability on Wednesdays

Thursday Availability (hours available)

Additional Comments regarding your availability on Thursdays

Friday Availability (hours available)

Additional Comments regarding your availability on Fridays

Do you have a valid driver's license? Do you have a valid driver's license? Yes No

Driver's License Number

Driver's License Expiration Date

Auto Insurance Company

Insurance Policy Number

Insurance Policy Expiration Date

Do you have any physical condition that may limit your volunteer activities? Do you have any physical condition that may limit your volunteer activities? Yes No

Please describe your physical condition

Emergency Contact Name

Emergency Contact Phone

Your Relationship to the Emergency Contact

I understand and agree that my volunteer service is at will, which means that it is for no specified period and may be terminated by me or Shepherd’s Center of Greater Tupelo at any time without prior notice, for any reason. I understand that misrepresentation or omission of facts may result in rejection of this application or termination. I hereby give my consent for the Shepherd’s Center to conduct a background check. I understand and agree that my volunteer service is at will, which means that it is for no specified period and may be terminated by me or Shepherd’s Center of Greater Tupelo at any time without prior notice, for any reason. I understand that misrepresentation or omission of facts may result in rejection of this application or termination. I hereby give my consent for the Shepherd’s Center to conduct a background check. Yes, I understand No

Digital Signature (please type your name)

Application Date