Horizons For Homeless Children

Required fields are marked with a *.

*Can you commit to at least six months of volunteering?
Yes No

*Do you have two hours a week to volunteer during: (check all that apply)
Monday-Thursday, 8am-8pm	Friday, 8am-6pm
No, I do not have 2 hours a week to volunteer.

Name:
*First Name:		*Last Name:

Address:
*Street:
*City:
*State:
*Zip:

Contact Information:
Home phone:		Work Phone:
*Email:		Mobile phone:

*Date of Birth:

(mm/dd/yyyy)

*Gender:

Male Female

Ethnicity: (optional)
African American	West Indian/Carribean	Latino	Asian/Pacific Islander
Native American	Caucasian	Other -

In case of emergency please contact:
*Contact Name:		Relationship:
*Home Phone:		Work Phone:
Cell Phone:

Occupation/ Student
Organization/ School
If employed, Organization...
Address
City
State
Zip

*How did you learn about Horizons for Homeless Children?
Choose:
Specify:

*Why would you like to work on behalf of homeless children?
*What do you hope to gain from this volunteer experience?

Please list your volunteer experiences, if any
Volunteer Experience: (organization, role, dates)
Volunteer Experience: (organization, role, dates)
Volunteer Experience: (organization, role, dates)

Although not required, do you have any experience with homelessness or "at risk" children? If yes, please list experience(s).

What language(s), other than English, do you speak fluently?

French	Spanish	Cambodian/Khmer
Portuguese	French Creole	Mandarin
ASL	Haitian Creole	Cantonese
Vietnamese	Other -

*What challenges do you expect in volunteering with us?
Is there any additional information you would like to let us know?

Please check all that apply:

I have received MMR vaccination (Measles, Mumps, Rubella)

I have had recent T.B. test (Tuberculosis) How recent?

I have had the chicken pox

I am CPR certified

Please list the names and daytime phone numbers of two references. If possible list at least one reference from your job (paid or volunteer) or school and one reference who has seen you interact with children.

*Name:		*Phone:		*Relationship:
*Name:		*Phone:		*Relationship:

*Which area are you interested in volunteering in?
Greater Boston (City of Boston and surrounding cities inside Rte 128) Central Massachusetts (Worcester County, Framingham, Attleboro and surrounding areas) Northeast (Merrimack Valley and North Shore Communities) Southeast (South Shore, Cape Cod and Southeast coastal communities) Western Massachusetts (Cities of Holyoke, Springfield, Northampton and surrounding cities)

Which Playspace training will you attend?: (Click here to see upcoming training sessions.)
*Location:		*Date:	(mm/dd/yyyy)

Volunteer Application Form