Hearts & Hands, Inc.
Volunteer Application

Address ___________________________________________________ Apt. # ____________

City/State ___________________________________________________Zip code __________

Phone (       )__________________ Work (       )___________________ext. __________

E-mail Address ___________________________________________________________

Date of Birth ____/____/______ (applicant’s under 18 years of age must fill out a Youth Volunteer Application)

Occupation _____________________________________________________________

Are you a full time student  No  Yes   If yes, name of school __________________________

Skills Assessment (Please give your best self-evaluation)
Please check one only:
 Professional - A professional tradesperson who is able to supervise all aspects of residential house construction.
 Handy - Accomplished do-it-yourselfer or has extensive experience.
 Unskilled - No specific skills, but willing to learn.
Area of Skill (Please check boxes below only if Professional or Handy is marked above. Check all that apply.)
 General contractor  Roofing  Plumbing  Drywall-hanging  Trim and finish
 Framing  Siding  Painting  Drywall-taping  Heating/cooling
 Electrical  Flooring  Landscaping
 Other, explain __________________________________________________________
______________________________________________________________________
______________________________________________________________________

Past involvement (Please explain)
(Your involvement in our program or a program similar to ours and/or your experience as a do-it-yourselfer.)
_______________________________________________________________________________________________
________________________________________________________________________________________________

Signature _____________________________________________________ Date ____ /______ /__________

(Prior to working with Hearts & Hands, Inc. you must fill-out and sign a Release and Wavier of Liability Form.)

For office             Date received________________________ Received By______________________________
Use Only
DO NOT WRITE     Contact Date_______________________________ 1st Work day_____________________________________
IN THIS SPACE
Emergency Contact Information
Applicant’s Name_______________________________________Date ____/____/_______

In case of an Emergency, Please Contact:

Name __________________________________________________________________

Address_____________________________________________ State_____ Zip________

Phone (     )____________________________Relationship __________________________

Any Hospital or Medical Practitioner not having access to your medical history may need the following information:

Allergies to medicine, food etc._____________________________________________________________
___________________________________________________________________________________________
Medication being taken _______________________________________________________
Date of last Tetanus shot______________________________________________________
Physical impairments__________________________________________________________
Other_____________________________________________________________________
__________________________________________________________________________

Personal Physician

Name____________________________________________________________________

Address _________________________________________________________________

City _________________________________________________State____Zip_________

Phone (     )___________________________________________

Personal Health Coverage

Company ________________________________________________ Policy Number ____________________________

This information will only be used in the case of an emergency.

Mail the original, signed application to:

Volunteer,
Hearts & Hands, Inc.
P.O. Box 331
Germantown, MD  20875-0331

Questions or requests for applications may be directed to:
Phone (301) 947-5770