Name:

Address:

City:      State:  IN MI OH IL     Zip: 

Birthday: format: xx/xx/xxxx

E-Mail:

Home Phone:   Work Phone:

Spouse Name:

Emergency Contact: Phone:

Do you have an interest in working with elementary school children?
Yes No Don't Know

Please list any special talents or skills (i.e.: sing, sew, etc...):

After receiving training, when would you be available to volunteer? (i.e.: Weekdays, Weekends, Holidays, Monthly, etc...)

How did you hear about us?

Please list three references that we may contact:

1. Name:   Phone:
2. Name:   Phone:
3. Name:   Phone:

Have you ever been convicted of or plead guilty to any crime(s):
Yes No
If "YES," please describe each in full:

As a condition of volunteering, I give permission for the Northern Indiana Center for History to conduct a background check on me, which may include a review of sex offender registries, child abuse and criminal history records.  I understand that, if appointed, my position is conditional upon the NICH receiving no inappropriate information on my background.  I hereby release and agree to hold harmless from liability the Northern Indiana Center for History, the officers, employees and volunteers thereof, or any other person or organization that may provide such information.  I also understand that regardless of previous appointments, NICH is not obligated to appoint me to a volunteer position.

Do you agree to abide by the above statement? Yes No

Are you under the age of 22? Yes No   If you are under the age of 18 you will need a signed note from your parent and/or guardian in order to volunteer for the Center for History.

Are you over the age of 65? Yes No

Please select the area(s) that you are interesting in (you can select more than one):

Admissions Desk          Exhibitions          Archives     
Special events              Cabin Days          Civil War Program
Clerical                         Data Entry           Mailings
TGIF (Summer event)     Annual Dinner      Tour Guide/Docent
Marketing/Publicity

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