Please provide the following contact information:

Name:
Title:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
County:
Home Phone:
E-mail:
Employer:
Work address:
Address (cont.):
City:
State/Province:
Work Phone:
Zip / Postal Code:

Date of Birth:
Sex:	Male Female

	One-to-One
	Compeer Calling
	Paired-to-Care

Please tell us how you heard about Compeer:

Please list your previous volunteer experiences:





Please check the population(s) and age groups
you would be willing to work with:

	Mentally Ill
	Developmentally Disabled
	Elderly
	Age 18-40
	Age 40+

	Weekdays
	Evenings
	Weekends

	CPR
	First Aid
	Both
	Neither

Who should we contact in case of an emergency?






Have you had any contact or work experience with persons
who have a mental illness, developmental disability or
who are elderly?







Your education:

Choose One... High School Some College Masters Degree Ph.D.




Name & location of college(s) attended?

Field of study/Degree obtained?