MADD SC VOLUNTEER APPLICATON FORM

                                                                         MADD                                                                       

Name:                                                                Phone:  (H)                             (W)                             
Address:                                                                                                                                              
City, State & Zip:                                                                                                                                
E-mail Address:                                                                                                                                 

I.                   SKILLS & INTEREST

Education Background:                                                                                                        

Current Occupation:                                                                                                           

Hobbies, Interest, Skills:                                                                                                       

Previous Volunteer Experience:                                                                                           

Are you a victim, or a relative or friend of a victim? (Please elaborate)___________

____________________________________________________________

____________________________________________________________

Is there a particular type of volunteer work you are interested in? (Check all that apply)

         __  One-on-one with a single person                                               __ Fundraising
          __  General Office Assistance                                                __ No Preference
        __  Public Speaking/Training/Writing                                             __Other:                               

Is there a particular group with whom your are interested in working with?  (Check all that apply)

           __Youth         __ Teens          __ Adults           __  Seniors                 __ Staff

          __ Male           __ Female         __ Victim           __ No Preference     __ Other:                        

Are there any groups you would not feel comfortable working with?  
     

   __ No                                            __ Yes                                  

II.                AVAILABILITY

At what times are you interested in volunteering? (Check all that apply)

__ Weekdays     __ Days                 __ Weekends             __ Days                   __ Flexible

__ Evenings                                     __  Evenings             __ Special Events

Do you have access to an automobile you can use for volunteer work?

   __ No                                            __ Yes

III.             REFERENCES

How did you hear about us?                    __Advertisement                      __ Looked for us

                                          __ From a Friend, Whom:                                                        __ Other:                    

Please list two names and numbers of someone we may contact as a personal reference.

            Name:                                                                                       Number:                                           

            Name:                                                                                       Number:                  __________  

Please copy, paste and send completed application to:   Juliet N. Smith, MADD SC , 2711 Middlburg Dr., Suite 307, Columbia, SC 29204,
or e-mail:  Juliet.Smith@madd.org.