Hearts & Hands, Inc.
Youth Volunteer Application

First name ______________________________ Last name __________________________________

Address ______________________________________________________ Apt. # ___________

City/State ___________________________________________________Zip code ____________

Phone (       )________________________________

E-mail Address _______________________________________________________________________

Date of Birth _______/ ______/ _________ (applicant’s under 18 years of age must fill out a Youth Volunteer Application)
Are you a full time student  No  Yes
If yes, school you attend_____________________________________________________________
Grade you are enrolled in ____________________________

Explain some of the things you would like to learn from our organization?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

I acknowledge with my signature that my child has permission to work as a volunteer with Hearts & Hands, Inc.

Please Print Parent/Guardian Name ___________________________________________________________________

Parent/Guardian Signature __________________________________________________Date______/_____/________

Youth 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