Empowered Choice Inc.
Staff & Volunteer Application

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you applying as a: *

Staff Member

Volunteer

Availability

(Check all that apply):

Full-Time

Part-Time

Weekends

Evenings

On-Call

Date Available to Start:

MM

DD

YYYY

Are you legally eligible to work in the U.S.?

Yes

No

Certifications/Licenses

(Check all that apply):

CPR/First Aid

CNA/HHA License

Medication Administration Certification

Background Screening Clearance

Other

Areas of Interest

(Check all that apply):

Assisting with Daily Activities

Organizing Donations & Supplies

Leading Recreational Activities

Transportation Assistance

Fundraising & Community Outreach

Administrative Support

Other

How often would you like to volunteer?

Weekly

Monthly

Occasionally

Have you ever been convicted of a felony?

Yes

No

Do you consent to a background check *

(required for staff & some volunteers)?

Yes

No

Agreement *

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that for staff positions, employment is contingent upon background screening, training, and meeting all requirements set forth by Empowered Choice Inc.

I Agree