Date:                               
Name:                                                                           Phone:                                                                    
Address:                                                                        Primary Language Spoken:                                      
                                                                                     Other Languages Spoken:                                        
College:                                                                        Advisor/Professor:                                                    
Educational Background:  Diploma/Degree: Relevant Coursework, Advisor, Professor, Course Work:
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Employment: Occupation/Employer:
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Previous Volunteer Experiences:  Organization, Position, and Dates
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Do you have a valid driver's license?  Y  or  N   Do you have access to a vehicle?  Y  or  N
Would you be willing to transport clients in your car?  Y  or  N

(If you transport, you will be listed on our Auto Insurance Policy for additional coverage over and above
your individual policy coverage.  Renewal House will reimburse you at the IRS rate)
Have you ever been convicted of a crime?  Y  or  N
Time Available?  (Number of hours per week or month - or on an "on-call" basis)
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Why are you interested in working for a domestic violence agency?
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
What areas of Renewal House programming are you interested in?
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Have you ever been a victim of domestic violence?  (It is your personal choice weather or not to disclose past 
experiences) If so, how do you think this could impact your ability to be a volunteer/intern at Renewal House?
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Have you ever been named as an alleged perpetrator or domestic violence?  If so, please explain.
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Do you feel you would be able to work objectively with any client we serve?
                                                                                                                                                                              
                                                                                                                                                                              
                                                                                                                                                                              
Please list two references:
Name:                                                                           Phone:                                                                     
Address:                                                                        Relationship:                                                            
                                                                                    
Name:                                                                           Phone:                                                                    
Address:                                                                        Relationship:                                                            
                                                                                    
Please list a person to contact in case of an emergency.
Name:                                                                            Work Phone:                                                            
Home Phone:                                                           
Signature:                                                                     Date:                                
Please mail or deliver your application to Renewal House at 3 Chapel Street, Canton, N.Y.  13617   
 

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