Alliance for Positive Health

Today's Date *

Name (First, Last) *

Address *

City *

State *

Zip *

Phone Number *

Alternate Phone Number

What is the best way to reach you?

Mail

Phone

Occupation

Employer/School Attending

Please list any knowledge and/or personal experience you have with HIV/AIDS.

Why do you want to volunteer with the Alliance for Positive Health?

Please list any skills, interests, hobbies:

Have you ever been convicted of a felony?

Yes

If yes, please explain

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Alternate Phone Number

Can you commit to the volunteer program for a specific amount of time?

Yes

If yes, how long?

For which event(s) are you interested in volunteering/interning? (Please check all that apply.)

Administrative Tasks (receptionist/ mailings, etc.) - As needed, throughout the year

BOO-jolais Wine Celebration - Friday, October 25, 2019

Columbia~Greene Garden Party - Saturday, August 31, 2019

Dining Out For Life® - Thursday, April 30, 2020

Holiday Gift Wrap - November 29 - December 24, 2019

Personal/Professional Reference *

Reference Phone Number *

By checking this box, I am certifying that I have read and understood this form. I affirm that the information provided on this form is true and complete to the best of my knowledge. I understand that completion of this registration form does not imply acceptance in to the Alliance for Positive Health volunteer program. If accepted, I agree to abide by all rules, policies and procedures as set forth by the Alliance for Positive Health. I also understand that there will be specific requirements to which I must adhere, including maintaining confidentiality of clients for each volunteer assignment. Age restrictions may apply. *

I understand & agree

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