CompeerCORPS Volunteer Form

CompeerCorps Volunteer Application

“Veteran Volunteers using the power of friendship to help fellow Veterans”

Through camaraderie, support and friendship, CompeerCORPS gives every veteran the opportunity to combat physical and mental obstacles as they reintegrate into civilian life. The Compeer of Suburban Philadelphia offers connections between those veterans referred to the program by a mental health professional and the VOLUNTEER.

Personal Information

First Name: *

Last Name: *

Middle Initial:

Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Email:*

Home Phone:

Cell Phone:

Work Phone:

Call at Work?:

Birthday:

day

month

year

Race:

Religion:

Marital Status:

Education/Training/Certifications (including any degrees held, CPR, etc.)

Hobbies, Special Interests, Skills (Please expand to assist with a good friendship connection)

Military Information

Branch of Service:

Dates Served

Type of Discharge:

Honorable

Dishonorable

Medical

(Please note that adishonorable discharge will not disqualify you from being a volunteer,however, we will not accept applicants thathave a dishonorable discharge WITH Federal prison sentence).

Other Information

Foreign Languages you can speak:

Can you speak sign language?:

Do you smoke?

Are you willing to be matched with a smoker? :

Is it important that your match be of a particular race and/or religion?:

What age range do you prefer?:

Would you want to work with a disabled Vetern?

Alcohol Use:

None

Rarely

Social

Daily

Current Employment

Company:

Occupation:

Company Address, City, State, Zip:

Supervisor’s Name:

Supervisor’s Daytime Phone:

Employment Dates:

Personal Reference
(The reference cannot be a relative and must have known you for at least one year)

Reference Name:

First

Last

Reference Phone:

How long have you know this person?

What is their relationship with you?

Personal Reference #2
(The reference cannot be a relative and must have known you for at least one year)

Reference Name:(2)

First

Last

Reference Phone: (2)

How long have you know this person?(2)

What is their relationship with you?(2)

Background Information

Birthplace City:

Birthplace State/Country:

Driver’s License # :

State:

Do you have a car?

Auto Insurance Company:

Has your license ever been suspended?

Have you ever been convicted of a crime (except minor traffic violations)?

Are there any misdemeanor and/or felony charges pending against you now?

Why do you want to volunteer for CompeerCORPS?

How did you hear about the CompeerCORPS program?

Are there any other important qualities/details for us to considering when looking for a veteran participant? If yes, please explain

I understand that as avolunteer I will support my connected friend to the best of my ability Inaccordance with the policies of the CompeerCORPS Program and will maintaincomplete confidentiality about all information on the individuals within theprogram.

Because the clientpopulation we serve is so vulnerable, we must screen our volunteers carefully.

Your cooperation incompleting this form is greatly appreciated.

All information will beheld strictly in confidence. Submission of an application and an interview doesnot obligate you to accept a volunteer opportunity with CompeerCorps.

Signature:*

Date of Signature:*

CompeerCORPS Volunteer Form

About Compeer

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