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2. Family Resources Center Volunteer Application
   P. O. Box 188
   Rocky Mount, VA 24151
   Phone: 540-483-5088
   24 Hour Hotline: 540-483-1234
4. Today's Date*
   Today's Date
5. Name*
7. Address*
8. 2nd Address
10. City*
11. State*
12. Zip Code*
14. Phone Number where you would prefer to be reached*
15. Email Address
17. Date of Birth
    Date of Birth
18. Current Age*
19. Are you a U. S. Citizen?*

    1. Yes
    2. No
20. Do you have a valid Virginia Driver's License?*

    1. Yes
    2. No
22. How did you hear of the Family Resource Center Volunteer Program?*
24. Have you ever been convicted of a felony?*

    1. Yes
    2. No
25. Have you ever been charged with assault and battery?*

    1. Yes
    2. No
26. Are you a "survivor" of domestic violence?*

    1. Yes
    2. No
28. Have you ever been homeless?*

    1. Yes
    2. No
29. Do you speak a foreign language?*

    1. Yes
    2. No
30. If you speak a foreign language, please specify language/languages.
32. What is your highest level of education?*
33. List any special interests.
35. Check the type of volunteer work you are interested in. (choose all that apply)*

    1. Babysitting
    2. Transportation
    3. Women's Activities
    4. Children's Activities

    1. Emergency Contact Person
    2. Office Help
    3. Other
36. If you chose Other in the previous question, please specify what type of volunteer work you are interested in?
38. Please put times on the days that you would be available to volunteer.
40. Monday
41. Tuesday
42. Wednesday
43. Thursday
45. Friday
46. Saturday
47. Sunday
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field