Union Gospel Mission Portland Addiction Recovery Homeless LifeChange

Name:

Date:

Address:

Cell Phone:

City, State, Zip:

Phone:

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Email:

Areas of Interest	.	.
- Thrift Store	Emergency Contact:
- Chapel Service	Relationship:
- Education	Phone:
- Homeless Services	Employers Name:
- Building Renovation	Work Hours:
- Holiday Meals	Days:
- Other	Work Phone

Special Skills:

Volunteer Training:

Hobbies or Special Interest:

Preferred Time to Volunteer

Time:

Days:

Date of Birth:

.

Have you ever been convicted of a felony?

- Yes , - No

.

If yes, what and when:

EDUCATION

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Select last year of school completed - 5, 6, 7, 8, 9, 10, 11, 12, College Grad, Some College

NON-FAMILY REFERENCE:

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(Pastor Employer Friend) Phone:

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DESCRIBE YOUR RELATIONSHIP WITH JESUS

I hereby agree that Union Gospel Mission is not responsible for any of my personal items that may be lost or damaged during volunteer period.

I hereby confirm and warrant that I have not been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense, nor have ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith.

By checking here you agree to the statement above.

Name of Parent or Guardian
(if under 18)

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