VOLUNTEER APPLICATION
____________
Name
Date
____________________________________________________________________________________
Mailing Address
Town/City
State
Zip
______________________________________________________________________________________________________________________________
Email Address
Home Phone
Work Phone
Cell/Beeper
_________________________________________
Occupation
________________________________________
Highest Level of Education Completed
__________________
Month/Day of Birth
Please answer the following questions to the best of your ability. We realize that some questions will relate to
situations which you may have no personal experience. Your application is kept confidential.
1. How did you become interested in the Samaritans?
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Have you volunteered with any other organization(s)?
 Yes
 No
3. If “yes”, which organization(s)? Please indicate if you are currently involved
_______________________________________________________________________________________
4. What are your hobbies and interests?
_______________________________________________________________________________________
_______________________________________________________________________________________
5. How do you think your friends would describe you?
_______________________________________________________________________________________
6. Have you ever known anyone who has committed or attempted suicide?
7. Have you felt suicidal yourself?
8. If “yes” how long ago?
 yes  no
 yes  no
9. Have you ever called the Samaritans, or do you know someone who has?
10. Have you ever been diagnosed with a mental illness?
 yes  no
 yes  no
11. If “yes” please indicate the diagnosis.
_______________________________________________________________________________________
12. Has it ever been recommended that you take medications for emotional well being and stability?
yes
no
13. If “yes”, please indicate what medication was recommended.
_______________________________________________________________________________________
14. How do you feel about the following?
People with psychological or mental disorders?
_______________________________________________________________________________________
Homosexuality (male and female)?
_______________________________________________________________________________________
Unwanted pregnancies?
_______________________________________________________________________________________
People who make obscene phone calls?
_______________________________________________________________________________________
15. How do you feel about people who commit or try to commit suicide?
_______________________________________________________________________________________
16. Do you think there are people in distress whom the Samaritans cannot help?
_______________________________________________________________________________________
Please list the name, address, and telephone number of three professional/business/educational references
1._____________________________________________________________________________________
2._____________________________________________________________________________________
3._____________________________________________________________________________________
Signature
Date
Please return completed application to:
The Samaritans, Inc. 103 Roxbury Street # 203 Keene, NH 03431
or email it to [email protected]
www.samaritansnh.org
A Monadnock United Way agency