Opportunity Manor, Inc. Volunteer Application

Full Name:	MI Last:
Address:
City:
State	Zipcode:
Phone Number:	(Day time)
Phone Number:	(Night time)
Email:
Date of Birth (XX/XX/XXXX)

How did you learn of this volunteer opportunity?
Newspaper Radio OMI website Referral Other If Referral or Other please list

I am seeking this volunteer position:
On my own Through my employer Non-paid Internship Fieldwork Service Learning Other If Other/Service-Learning please list

What do you hope to gain by voluteering? (*)

In what program area(s) would you like to volunteer?

If Other area(s)/Program(s) please list:

Please indicate tasks you WOUNLD NOT LIKE TO volunteer for:

What day(s) are you available?


What time(s) are you available?

OMI Counties served include: Sherburne, Benton, Stearns

Please select the Geographic area(s) in which you would be willing to volunteer? (*)
St. Cloud Sartell Waite Park St. Joseph Sauk Rapids Makes No Difference

Employment Experience - Optional (Please list current employer with a phone number)

Volunteer Expereince

If yes, please list organization, dates, contact person and telephone number.



Release: I hereby release Opportunity Manor Inc. and all sponsoring organizations for and all claims that may arise from or result in any expense, personal injury, loss or damage incurred to me or by me during my participation in Opportunity Manor Inc projects.

Permission to use Photographs: I also grant permission for Opportunity Manor Inc and sponsoring organizations to use group photos, film, and videos of me for any promotional or other use either associated with the project or sponsoring organizations, including use on the Opportunity Manor Inc. website.

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I certify that the information I have given in this application is accurate. I understand that my volunteer status may be subject to termination if I have misrepresented application information and/or fail to adhere to program policies and guidelines established by Opportunity Manor Inc. and Department of Human Services. I understand that

• Submitting this application does not guarantee my selection for a volunteer position and that assignment of volunteer work is based on assessment by staff
• Clearance of driving and criminal records is completed for all volunteer applicants with the results used as part of the selection process.
• There may be sharing of certain volunteer information within our agency, with contract service providers and with Clients
• My services are on a volunteer basis without anticipation of financial reimbursement and I indemnify and hold harmless Opportunity Manor Inc. and its employees, agents, leaders, instructors, contractors, and volunteers from and against all claims by an officer, employee agent, leader, instructor, contractors or volunteer of Opportunity Manor Inc. as a result of, or during my participation in volunteer services.

I acknowledge that I have carefully read and fully understand this agreement and it contents. I am aware that this is a release of liability and contract between myself and Opportunity Manor Inc. volunteer program and/or its officers, employee agents, instructors and volunteers, and I sign on my own free will.

If my application is approved and I accept a volunteer assignment, I agree to

• Keep all client information confidential
• Provide written summaries of volunteer activities as specified
• Notify the coordinator of any changes to mailing address, status of drivers license and vehicle insurance.

I certify that I have read, fully understand and accept all terms of the foregoing Application Release.

Date (XX/XX/XXX):

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