Name:                                                                                                                                 Date:                                               

Address:                                                                                                                              Zip:                                    

Telephone:                                                     Cell                                             SSN                                                    

E-mail:                                                                                      Gender: M          F            

Date of birth          /      /         

Local Congregation or Faith Affiliation:                                                                    

Do you have health problems or physical conditions that limit what you are able to do?

Yes       No        Describe:                                                                                                                                                            

How did you hear about the Volunteer opportunities at TMM?                                                                                                      

Your Skills/Talents/Interests: 1.)                                               2.)                                            

3.)                                              4.)                                              5.)                                            

Is there a specific program for which you would like to volunteer?                                                                                               

REFERENCES (2 individuals TMM may contact) *Not to be shared with outside sources

Name:                                                                                   Phone:                                                           

Name:                                                                                   Phone:                                                 

Are you volunteering to apply toward court ordered community service? Y_____ N_____

Nature of violation:______________________________________________________ Required hours:________________

Volunteers with a record of crimes against children can not be assigned to any TMM program.

Are you supportive of TMM Family Services Mission Statement? Y       N____

Volunteer’s Signature:                                                                                 Date:_____________________

TMM Family Services, Inc. has never promised me any financial remuneration for my services nor do I expect to receive any financial remuneration other than agreed upon mileage, meals, and supplies. I understand that in volunteering my services to TMM, I am holding them harmless from any injury that might result from my own negligence. I agree to abide by the terms of this volunteer waiver.

                                                Signature                                                                                                            Date

Days available:  Su    M    T    W    Th     F     Sa       

(Revised 02/07)