3401 Lake Ave., Suite 4 | Fort Wayne, IN 46805 | 260-424-3505 or 888-219-6868

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Online Volunteer Form

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Application for: *

Name: *

Date of Birth: *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Email: *

Are you currently volunteering anywhere?: *

Name of agencies where you are currently volunteering:

Would you like to be contacted to find a place to volunteer?: *

Would you like to volunteer for one day special events?: *

Do you need to complete a required number of volunteer hours for a class, service club, or court order?: *

Are you a veteran or a current service member of the military?: *

AREAS OF VOLUNTEER WORK I AM INTERESTED IN:

Accounting & Bookkeeping

Animals

Airport Host

Bulk Mail & Packet Assembly

Carpentry

Coat Check @ Civic Theater

Computer Programming/Web

Data Entry

Environmental Issues

Food Banks

Health Care

Homeland Security

Host/Greeter at Special Events

Income Tax Assistance

Law Enforcement

Legal

Library

Military Families & Veterans

Museums

Music

Office Work/Clerical

Receptionist

Sewing/Knitting

Translator

Tutor & Literacy

Usher

Unemployment/Food Stamps Intake

Do you hold any special licenses?:

Which Ones?:

Do you speak and foreign language?:

Which Ones?:

During your volunteer time, you are covered by CIMA supplemental insurance at no cost to you. Part of the benefit is a $2,500 life insurance policy. Please designate a beneficiary or write “estate”.

Beneficiary Name: *

Relationship: *

Beneficiary Address: *

Beneficiary Phone: *

By pressing the Submit button below, I approve/authorize my signature on this form.

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