Change Text Size:

Volunteer Application

Application to Volunteer at the Minnesota Brain Injury Alliance

Thank you for your interest in volunteering at the Minnesota Brain Injury Alliance. Please fill out the following form to submit to our Volunteer Department. If you have any questions, please contact us at 612-378-2742, 800-669-6442, or e-mail us.

Contact Information
Name:*
Address:*
City:*
State:*	Minnesota Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:*
Daytime Phone:*
Evening/Cell Phone:
E-mail:*
Please list any special considerations (i.e. physical or medical) that we should be aware of:
Emergency Contact
Name:*
Relationship:*
Daytime Phone:*
Evening/Cell Phone:
Volunteer Experience
Please list places where you have served as a volunteer:
How did you learn about volunteering with us?
Current or Most Recent Employment
Employer:
From:
To:
Position:
Education
Are you presently attending school?*
	Yes No
If so, will you receive academic credit for your volunteer work?*
	Yes No
Highest Degree Attained/School
Criminal Background
Have you ever been convicted of an offense for which a pardon was not granted?*
	Yes No
Availability for Volunteering
Time:	Daytime Evening Weekend
Days:	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Available:	Ongoing Occasional Less than 10 hours per week More than 10 hours per week
Placement
Why do you wish to volunteer for the Minnesota Brain Injury Alliance?
What skills, interests, hobbies or experiences do you have that may help us place you?
Why types of volunteer jobs or activities interest you?
Do you have a brain injury?*
	Yes No
If so, how did you receive your injury?
Please read the following:
Volunteers are considered for placement without regard to actual or perceived race, color, religion, sex, national origin or ancestry, age, disability, veteran status, sexual orientation, marital status, status with respect to receipt of public assistance or any other basis protected by federal, state or local law.
* I acknowledge that all statements made on this application are true, complete and correct to the best of my knowledge and belief. I also understand that falsification of this application can disqualify me from consideration or result in dismissal upon discovery. I understand that submitting this information does not guarantee my acceptance into the volunteer program, and that assignment of volunteer work is based on assessments made by Minnesota Brain Injury Alliance staff. I understand that as a volunteer, I will be required to abide by all rules and regulation of the Minnesota Brain Injury Alliance.
Does two plus one equal the color red?
	Check if yes
Please call 612-378-2742 or 800-669-6442 with any questions. Thank you.