Volunteer Application

Lutheran Social Services, witnessing to the Gospel of Jesus Christ, provides exceptional health, human and senior living services by supporting persons in achieving an optimal quality of life.

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Salutation:

First Name: *

Middle Initial:

Last Name: *

Address (Line 1): *

Address (Line 2):

City: *

State: *

Zip Code: *

Primary Phone: *

Cell Phone:

Email Address: *

Employer (optional):

Work Phone:

Is it appropriate to call you at work?:

Yes

School (if currently a student):

Birth Date: *

Church Affiliation (optional):

Volunteer position for which you are applying?:

Have you ever been convicted of a crime?: *

Yes

If yes, please explain:

Have you ever been an employee of LSS?: *

Yes

If yes, please list program or service/position/dates of most recent employment.

LSS Program or Service:

Position:

Employed From::

Employed To::

Please note any health or physical limitation that you may have (including allergies); or need for any specific accommodations:

Please list your special skills, interests or hobbies:

Please list any certifications or credentials you hold:

Previous or current occupations:

Previous or current volunteer positions:

How did you learn of this volunteer opportunity?:

Languages spoken (other than English):

I am available to volunteer with the following frequency:

Days per week:

Days per month:

As needed:

Emergency Contact:

Name:

Address (Line 1):

Address (Line 2):

City:

State:

Zip Code:

Primary Phone:

Cell/Work Phone:

Relationship:

Reference #1 (not relatives):*

Name: *

Address (Line 1): *

Address (Line 2):

City: *

State: *

Zip Code: *

Primary Phone: *

Relationship: *

Reference #2 (not relatives):*

Name: *

Address (Line 1): *

Address (Line 2):

City: *

State: *

Zip Code: *

Primary Phone: *

Relationship: *

For Stephen Ministry Applicants only, please list your pastor as reference #3:

Name:

Address (Line 1):

Address (Line 2):

City:

State:

Zip Code:

Primary Phone:

Relationship:

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Lutheran Social Services South Central Pennsylvania, 1050 Pennsylvania Ave., York, PA 17404 888.404.3500 | 717.854.3971

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Volunteer Application