LBDA Volunteer Application Question Title * 1. Personal Information Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. How would you prefer to be contacted? Phone Email Question Title * 3. What is your age range Under 18^ 18 – 24 25 – 34 35 – 44 45 – 54 55+ Other (please specify) Question Title * 4. Birthday Month January February March April May June July August September October November December Question Title * 5. Have you ever been convicted of a crime? (You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated, convictions more than two years old for marijuana related offenses for personal use, and misdemeanors for which probation was complete and the case judicially dismissed.) If Yes, please explain in the section provided Question Title * 6. Education Some High School High School Graduate Some College College Graduate Advanced Professional Degree No response Question Title * 7. Please describe any previous work experience that may be pertinent to your volunteer interest (Check all that apply) Marketing/Public Relations Management NonProfit Management Fundraising Education Special Events Healthcare Science Finance Legal Other Question Title * 8. Does your current employer have (check all that apply) Program for volunteering Donation matching program Grant preferences to organizations where you volunteer Other (please specify) Question Title * 9. Have you had any previous experience as a volunteer? If so, with what organizations, and what kind of work did you do? Question Title * 10. Are you a member of any professional, civic, or social clubs? (Check all that apply) Rotary Kiwanis Elks Local Chamber of Commerce/Business Association Fraternity/Sorority Garden Club Other Question Title * 11. How did you learn about our volunteer opportunities? LBDA website Referral/word of mouth LBDA Newsletter Internet Search Volunteer Listing (Idealist, Volunteer Match, Board Net, etc) Social Media (Facebook, Twitter, LinkedIn, Pintrest) Other Question Title * 12. Please describe your reason for volunteering with LBDA: Why, at this particular time in your life, have you chosen to volunteer with us? What do you hope to accomplish? Question Title * 13. Generally speaking, where do you want to focus your volunteer efforts? (Check all that apply) Increase awareness of LBD Support others affected by LBD Raise funds to address the LBD disease burden. Assisting LBDA with legal, financial and other operational issues Other: Question Title * 14. How long would you like to volunteer? One-time project Once annually activity On-going activity (usually requires a one year commitment) Question Title * 15. Date you’ll be available to start: Question Title * 16. Please provide the first and last name and contact number for 3 references. Question Title * 17. I certify that all information in this volunteer application are true and complete to the best of my knowledge. I understand that any false statement, omission or misrepresentation in my application or placement interview may result in the rejection of my application or discharge from the volunteer program.2. I understand that as a part of the final volunteer selection process, I may be required to provide reference and/or consent to conduct a background screening. I understand that all information collected during this background screening will be limited to that appropriate to determine my suitability for this particular type of volunteer work and that such information collected during the screening will be kept confidential.3. I understand that as a volunteer, I am offering my services of my own free will without any expectation of compensation, benefits, or insurance of any kind. Please type your complete name below as acknowledgment of the above statement. If under the age of 18, a parent/legal guardian's name is also required. Name/Date Parent/Guardian's Signature (if applicable) and date Done