Interact Volunteer/Intern Application
First Name
Middle Initial
Last Name
Home Phone
Work Phone
Email Address
Street Address
City
State
Birthday (Month/Day/Year)
Place of Employment
Zip
Social Security Number
Job Title
Supervisor
Educational Background
High School Attended____________________________
Diploma/GED Received? ___Yes ___No
If yes, date received: ______________
College Attended________________________________ Major: ________________
Degree Received? ___Yes ___No If yes, date received: ______________________
Commitment
If you are interested in working directly with our clients, can you commit to attending a
month-long training class (a month of Saturdays from 9am to 5 pm or Tuesdays and
Thursdays from 6:00-9:00 pm)? ___Yes ___No
Are you able to commit to volunteering with Interact for at least one year following
your completion of training? _____
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Interact Administrative Office • 612 Wade Avenue • Raleigh, NC 27605 • (919) 828-7501
More About You
Please explain briefly your reasons for wanting to volunteer with Interact at this time:
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What do you hope and/or expect to receive from a volunteer experience at Interact?
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What skills/qualities/experience will you bring to Interact as a volunteer?
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If you will be involved with Interact as part of an internship, practicum, or for other
academic purposes, please list your requirements below (number of hours to be
completed, length of placement, supervision requirements, etc.):
Please list any other volunteer organizations or activities you have participated in and
length of service:
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Interact Administrative Office • 612 Wade Avenue • Raleigh, NC 27605 • (919) 828-7501
Please list the name of your Church, Synagogue, or Temple, etc: (Some of our funding
comes from faith-based organizations. They are interested in whether their members
are volunteers with our organization.)
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Do you speak another language? _____Yes _____ No
If yes, what language(s) and are you fluent?
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How did you learn about Interact?
Media____ United Way____ Friend/Acquaintance____ Other: ____________
Have you ever used any of Interact’s services? ____Yes ____ No
If yes, which Interact service(s) have you used? (please circle all that apply)
Counseling
Support Group(s)
Shelter
Court Advocacy
SAFE Center
When were you involved with Interact’s services? _________________________
Have you ever been charged with or convicted of a crime? ____Yes ____ No
If yes, please explain:
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Do you have any special needs or accommodation that we need to be aware of in order
for you to volunteer or intern?
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Thank you for completing Interact’s Volunteer Application!
Please sign and date the application below.
Signature
Date
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Interact Administrative Office • 612 Wade Avenue • Raleigh, NC 27605 • (919) 828-7501
References
Reference Consent:
I do hereby authorize Interact to verify any representations made by me, whether oral or
written, concerning my application for the position of VOLUNTEER. Further, I hold harmless
any individual or firm for any information they may provide. I understand that Interact may
contact individuals or organizations other than those I have provided as references or other
information, which may be pertinent to my application for this position.
Signature
Date
Please list 3 references below, including at least one professional reference. We prefer that your
professional reference be someone who has supervised you in some capacity. No family members
please. EACH REFERENCE MUST SUBMIT A WRITTEN RECOMMENDATION LETTER TO
COMPLETE YOUR APPLICATION. PLEASE ATTACH REQUIRED LETTERS OF
RECCOMMENDATION.
1)
Name (Professional)
Street Address
Relation to you
City
State
Daytime Phone
Zip
Evening Phone
2)
Name (Personal)
Street Address
Relation to you
City
State
Daytime Phone
Zip
Evening Phone
3)
Name (Personal)
Street Address
Relation to you
City
State
Daytime Phone
Zip
Evening Phone
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Interact Administrative Office • 612 Wade Avenue • Raleigh, NC 27605 • (919) 828-7501