REICHERTHOUSE

Personal Information

Name:

Street:

City: State: AL AK AZ CA CO CT DC DE FL FM GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip:

Male Female

Background (Must be at least 17 to volunteer)

Month: January February March April May June July August September October November December 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: 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

Social Security Number (Required):

ID/Driver's License Number:

Contact Information

Home: Work: Cell:

E-Mail:

Areas of Interest

General

Tutoring

Administration

Recreation

Mentoring (Approval Required)

Intership (Approval Required)

Are you in college? Yes No

Name of College/University?

Anticipated Date of Graduation?

Are you applying for work study?

Medical and Background Information

Do you have any physical limitation? Yes No

If yes, what?

Are you on any medication? Yes No

If yes, what?

Have you ever used any illegal substance? Yes No

If yes, what?

Have you ever been convicted of a felony? Yes No

If yes, please explain?

Please initial below. This acknowledges that prior to being allowed to tutor and/or volunteer at the Reichert House Youth Academy, that a criminal background check will be performed by the Gainesville Police Department, they acknowledge that all information given above is true and accurate.

Initials