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Menu

Home
Programs
- On Track
Services
Resources
- YouExist
- Community Compassion Care
Info
Volunteer
Donate
Make An Appointment
Contact

Home
Programs
- On Track
Services
Resources
- YouExist
- Community Compassion Care
Info
Volunteer
Donate
Make An Appointment
Contact

Menu

Home
Programs
- On Track
Services
Resources
- YouExist
- Community Compassion Care
Info
Volunteer
Donate
Make An Appointment
Contact

SSH-CCBHC VOLUNTEER APPLICATION

Silver State Health VOLUNTEER APPLICATION

Step 1

Step 2

Step 3

Step 4

References

Name

Address

City

State

Zip

Home Phone

Work Phone

Your Email

Previous Volunteer Experience

Occupation (Past occupation if retired)

Other information that will help us make a good match (such as education, general interests/hobbies)

Languages Spoken:

Availability and Volunteer Assignment Preferences

Please Check All That Are Applicable:

I Am Available

Mornings (Mon-Fri)

Afternoons (Mon-Fri)

Evenings (Mon-Fri)

Weekends

Once A Week

More Than Once A Week

One Time Only

As Needed

OTHER

I Could Serve More Than One Person:

Yes

No

Do You Have A Valid (State) Driver’s License?

Yes

No

License Number:

Vehicle License Plate Number

Insurance Company:

Policy #:

Have You Ever Been Convicted For Violation Of Any Laws, Traffic Or Otherwise?

Yes

No

If Yes, Please Explain:

Do You Have Any Physical Condition that May Limit Your Activities?

Yes

No

If Yes, Describe

Who To Notify In Case Of An Emergency?

Telephone Number:

Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.

Name

Phone

Address

Relationship

Name

Phone

Address

Relationship

Name

Phone

Address

Relationship

Comments:

I hereby give my consent to contact my references; to contact my employers, past and present; and to conduct a background check.

Signature Of Applicant

Date

(702) 471-0420

info@silverstatehealth.org

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