Volunteer Application

Today's Date*

Personal Info

Name*

Email*

Cell Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Date of Birth*

Gender*

Male
Female

Emergency contact name*

Cell Phone Number*

Check all applicable boxes

Behavioralist
CPR certified
First Aid certified
MD
Nurse
Occupational therapist
Physical therapist
Special ed teacher or aide
Other therapist or medical professional

If Other therapist or medical professional, please describe

Special needs experience on a scale of 1 to 5*

1 (very little)
2
3
4
5 (very much)

Please describe your special needs experience, education, training, etc. if any (none required)*

My strenghs that I bring to children include:*

Check boxes of serving interest*

Administrative assistance
Being a buddy for children w/ special needs
Being a buddy for siblings
Crafts
Games
Music/ Entertainment
Leading group activities
Photography/ Video
Registration/ Check in
Security
Serving refreshments
Wherever needed

I am comfortable working with children who are:*

Cognitively challenged
Emotionally challenged
Hard of hearing
Hyperactive
Medically fragile
Non-verbal
Siblings without special needs
Vision impaired
Any of the above

I am uncomfortable with:*

I would like you to know this about me:

Thank you for completing this form. If you have any questions, contact Dan Adragna by texting 916-390-2900 or emailing [email protected].

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