Please provide the following contact information:

First Name
Last Name
Middle Initial
Choose one	Mr. Mrs. Miss Ms.
Street Address
City
State
Zip Code
Work Phone
Home Phone
Cell Phone
E-mail

Emergency Contact:

First Name
Last Name
Relationship
Street Address
City
State
Zip Code
Work Phone
Home Phone
E-mail

Personal or Professional References:
Please list only references who are not related to you.

1. Name:
   
   Address:
   
   Phone Number:
    

2. Name:
   
   Address:
   
   Phone Number:

Personal Data:

Date of Birth: Choose Month January February March April May June July August September October November December    Choose Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year

Are you currently a student? Yes   No

High School Graduate: Yes   No     If no, what year

College Graduate: Yes   No     If no, what year

College Degree: Yes   No     If no, what year

Major:    Type of Degree:

Are you presently employed? Yes   No  Retired

If yes, Employer's Name:

If yes, Employer's Address:

If yes, Employer's Phone:

Please list community affiliations and volunteer experience:

Have you been referred by anyone? If yes, by whom:

Which day(s) of the week are best for you to volunteer?
Please check all that apply:

Monday  Tuesday  Wednesday  Thursday  Friday

Which time is best for you to volunteer?

Morning  Afternoon  Evening

Please check all areas in which you are interested:

Assisting a child or teen with homework
Mentoring a teen
Reading to or reading with a child
Assisting with special events
Clerical
Assisting in the office
Sharing a special skill with our seniors, teens, or school children
Other: Please specify:

Filling out this application does not guarantee a placement.  Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex. 

I understand that all volunteers are subject to all rules and regulations of Bethlehem Center.

Checking this box indicates your approval for us to check references.  It will permit us to do a criminal background check as well.  Your signature also signifies that the above information is accurate and correct to the best of your knowledge.

Verification code

You may also print out this form and mail it to us at:

You may also print out this form and mail it to us at:
Bethlehem Center
Amy Hutchison, Development Specialist
2705 Baltimore Avenue
Charlotte, NC 28203

Phone: #704-621-2058, ahutchison@bethlehemcenter.org