Full Name: _________________________________________     Date: ______________

Home Address: ______________________________________     City: ______________

State: __________     Zip Code: __________     How long have you lived there? __________

If less than 3 years, what was your last address? ____________________________________

Home Phone: ____________     Voice/TTY           Work Phone: ____________     Voice/TTY

Other phone (Cellular Phone, E-mail address, etc.) ____________________________________

Work Information _____________________________________________________________
                                        (Business Name)                                        (Street)

___________________________________________________________________________
            (City)                               (State)                  (Zip)                  (Phone)

Occupation: _______________________     How long have you worked there? __________

List your sign language experience ________________________________________________

List other volunteer experience ___________________________________________________

______________________________________________________________________________

Have you been convicted of a felony?               Yes          No
If Yes, please explain____________________________________________________________

Do you have a valid Ohio driver's license?               Yes          No

Do you have the state minimum auto liability insurance?               Yes          No

Deaf Services Center is an equal opportunity agency and does not discriminate in use of qualified volunteers on the basis of age, sex, race, religion, national origin, or disability. This section is used for demographic information and for the purpose of making the most compatible match possible. Your assistance in completing this section is appreciated but not mandatory.

Date of Birth ____________     Marital Status _______________     Race __________


It is the practice of Deaf Services Center to involve only those volunteers who will provide the most positive experiences for the Deaf community and youth. Reference checks, police checks, fingerprinting, and interviews may be used to screen potential volunteers.


I have read this application and agree that the information I have given is true and complete to the best of my knowledge.

Signed _____________________________________     Date ______________