Name: ___________________________________________Date_______________

Address: _________________________________________Phone:______________

Referred by:______________________________________Phone:______________

Please circle your age range: 18-30     31-49     50 or older

Please circle areas of interests:

Direct Services to Residents:
Group Sessions, Medical Education, Food Service, Teaching, Mentoring,

Social Events, Other: _______________________________________________

Services to Empire Recovery Center (ERC):
Clerical, Fund Raising, Carpentry, Painting, Multimedia Creation,

Maintenance, Newsletter Publication, Other: ________________________

1. Do you have any experience working with persons in recovery?

_____________________________________________________________________

2. How many hours per week are you available:_______________________

3. Which days of the week are you available?__________________________

4. When can you start?______________________________________________

5. List some of your skills, talents, or hobbies that you think will benefit the ERC

_____________________________________________________________________

_____________________________________________________________________

6. Why do you want to volunteer at the ERC?

_____________________________________________________________________

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