Spring Dell Center, Inc.

6040 Radio Station Road

La Plata, Maryland 20646
www.springdellcenter.org

Volunteer Application
All volunteers are considered for all positions without regards to race, color, religion, sex, national origin, age,
marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally
protected status.
Please Print Date: _________________
TYPE OF VOLUNTEER WORK INTERESTED IN: Retail, Thrift Store Clerical OTHER:
_____________________________________

Fundraiser Assisting with Lunch (Feeding) Job Training Arts/Crafts _____________________

_____________________
Electronics Testing Computers Recreational Outings Residential Services _____________________
_____________________
Transportation 1-on-1 Activities Music/ Instruments Cleaning Reading

NAME: LAST: FIRST: MIDDLE:

MAILING ADDRESS:

CITY: STATE: ZIP CODE:

HOME PHONE: WORK / CELL PHONE: E-MAIL:

In Case of Emergency Contact Name: Phone:

Spring Dell Center, Inc. is dedicated to assisting individuals with disabilities in achieving their highest level of
independence by providing support and opportunities for the quality of life they desire within their community.
 VOLUNTEER OR WORK HISTORY
NAME OF BUSINESS ADDRESS & PHONE NUMBER

DATES WORKED/VOLUNTEERED

FROM:___________________ TO:____________________

DUTIES:

[ ] Paid Employment [ ] Volunteer Work

NAME OF BUSINESS ADDRESS & PHONE NUMBER

DATES WORKED/VOLUNTEERED

FROM:___________________ TO:____________________

DUTIES:

[ ] Paid Employment [ ] Volunteer Work

NAME OF BUSINESS ADDRESS & PHONE NUMBER

DATES WORKED/VOLUNTEERED

FROM:___________________ TO:____________________

DUTIES:

[ ] Paid Employment [ ] Volunteer Work

SPECIALIZED SKILLS AND KNOWLEDGE

Describe any specialized training you have received and list any skills or knowledge that would be beneficial
 AVAILABILITY

How often are you available per week ____________ or per month ____________

Check Availability: (Please note this can be flexible)

One-time Only Weekly Activities Monthly Activities
Fundraising Event Once a week Once a month
Holiday Party Twice a week Twice a month
Auction Three times a week Three times a month
Other ____________________ Four times a week Four times a month

Days of week available:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Additional Comments: ______________________________________________________________________________

_________________________________________________________________________________________________
Please tell us why you would like to volunteer at Spring Dell Center.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please tell us how you heard of Spring Dell Center.

Family Friend Advertisement Internet Other _________________________________________

_________________________________________________________________________________________________

List Three Character References:

Daytime Evening
1) Name Phone Phone

Daytime Evening
2) Name Phone Phone

Daytime Evening
3) Name Phone Phone

You signature is required below to indicate that all of the information stated in this application are true.

Signature of Applicant:____________________________________________________ Date:____________________________________

Signature of Guardian: ____________________________________________________ Date:____________________________________

(*Required if applicant is under the age of 18)

 Pinkerton Consulting & Investigations
Authorization for Release of Information
In connection with my application for employment or volunteering, I authorize Pinkerton Consulting Information Services
and their respective agents, to solicit information about my criminal background history. I AUTHORIZE, WITHOUT
RESERVATION, ANY GOVERNMENT AGENCY CONTACTED BY PINKERTON CONSULTING &
INVESTIGATIONS OR THEIR RESPECTIVE AGENTS, TO FURNISH THE ABOVE REFERENCED
INFORMATION.
I release Pinkerton Consulting & Investigations, their respective employees, agents and government agencies providing
information or reports about me from any and all liability arising out of the release of any such information or reports.

NAME (Print):_____________________________________________________________________________________________
(First) (Middle) (Last)

OTHER NAMES USED (Including Maiden Names):_______________________________________________________________

CURRENT ADDRESS:______________________________________________________________________________________

COUNTY:_____________________________ CITY:______________________________ STATE:________________________

ZIP CODE:____________________________ NUMBER OF YEARS AT THIS ADDRESS:_______________________________

TELEPHONE NUMBER: ___________________________________ DATE OF BIRTH: _______________________________

DRIVERS LICENSE #:_______________________________________ STATE OF ISSUE:_______________________________

EXPIRATION DATE:_____________________________ SOCIAL SECURITY NUMBER:_______________________________

PRIOR ADDRESS IF LESS THAN 2 YEARS AT THIS ADDRESS

ADDRESS:_______________________________________________________________________________________________

COUNTY:_____________________________ CITY:_____________________________ STATE:_________________________

ZIP CODE:_____________________________ NUMBER OF YEARS AT THIS ADDRESS:______________________________

NAME OF MOST RECENT EMPLOYER:______________________________________________________________________

ADDRESS:________________________________________________________________________________________________

COUNTY:______________________________ CITY:____________________________ STATE:_________________________

ZIP CODE:____________________________ # OF YEARS EMPLOYED AT THIS ADDRESS___________________________

I have been advised of my rights under the Fair Credit Reporting Act. If negative information should be presented in my name, I
reserve the right to contact Pinkerton Consulting & Investigations for clarification.

_______________________________________________________________ DATE:___________________________________
SIGNATURE - (Parent Signature, if under 18)

WITNESS____________________________________________________

RETURN TO SPRING DELL CENTER

Fax #: (301) 870-2007

(04/07)