Full Name:

Date of Birth:

Present Address:

Permanent Address (if different from above):

E-mail:

Home Phone:             Cell Phone: (if any) 

Availability: Hold Ctrl & Click to choose multiple times.

Mornings Only Afternoons Only Weekends Only Weekdays Only Anytime Monday Tuesday Wednesday Thursday Friday Saturday Sunday Available When Needed Available for Special Events Only

Do you have any physical or mental condition which may limit your ability to serve as a volunteer?

Yes   No

If yes, please describe:

Have you ever been convicted of a crime?  * A criminal background check is required.

Yes   No

If yes, please describe: **A positive does not mean that you are immediately eliminated as a potential volunteer.

Do you have a preference for the service in which you would like to volunteer? Hold Ctrl & Click to choose multiple areas.

Emergency/Disaster Services Health & Safety Services Financial Development Volunteer Services Blood Services Special Events Administration Youth Services International Services No Preference

Have you ever volunteered with the American Red Cross?  Yes   No

If yes, please list Chapter name and state:

        Total years with previous Chapter (if applicable) 

        Total years with Red Cross (if applicable) 

Where else do you volunteer and how long have you been volunteering there? Or if you no longer volunteer at

an agency, why not?

Employer:

Your Job Title:

American Red Cross work location preferred: Forsyth County Davie County Stokes County Yadkin County Where I am Needed

Emergency Contact:

                                    Name:

                                    Address:

                                    Home Phone:

                                    Work, Cell or Other Phone: 

                                    Relationship to You:

High school/state you attended and year you graduated:

College/state you attended, degree received and year you graduated:

Health problems, needs or allergies that staff should know about in case of emergency while volunteering for Red Cross:

Optional:

The following two questions are optional to answer.  These questions help us gather information required by our National Headquarters as part of our efforts to promote diversity.

Gender: Female Male

Ethnicity: African American American Indian Asian or Pacific Islander Caucasian Hispanic Other

Please indicate if ethnicity not covered above:

If there is anything that you would like to tell us that is not in the above application, please do so here:

Thank you for taking the time to fill out this application and for volunteering with the American Red Cross.  We will be contacting you as soon as we have all available information.  If you would like to check on your application,

please contact us at 724.0511.

Please submit application by clicking the Submit button!