Contact Information Background Information
Date of Birth*
Gender Identity Female Gender Queer Intersex Nonbinary Male Transgender Female Transgender Male Other/Prefer to self-describe Prefer not to share
Preferred Gender Pronoun She/her/hers He/him/his They/them/theirs Interchangeable No Pronoun/Name only Other
How did you hear about us? Education and Employment History Current/Most Recent Employer
Please indicate Duties/Primary Responsibilities at Employer 1* Past Employer 2
Please indicate Duties/Primary Responsibilities at Employer 2* Volunteer Interests
Please let us know how you would like to volunteer at OUT HEALTH. Check all that apply:
Please check any and all that represent your typically available/preferred hours to volunteer (mornings are generally 8:00 - 1:00 pm, afternoons are generally 1:00 – 5:00 pm evenings are generally 5:00 - 9:00pm):
Please provide a brief statement in your interest in volunteering for OUT HEALTH INC and supporting the LBGTQ+ community.
Our Volunteer Coordinator may contact up to three references as part of our application process. Please list professional references and/or friends and family.
Reference 1 Reference 2 Reference 3 Emergency Contact 1 Emergency Contact 2
Please let us know if there are any special circumstances or medical information we might need to know about you which may present risk during an emergency (i.e. allergies, heart conditions, medications you are taking, etc.).
If you wish to volunteer to satisfy a community service requirement, please let us know who the service is required by (school, court-order, etc.), how many hours you need to complete, when the service must be completed, and name/email/phone number of the contact person is to whom we should certify your service completion hours. Legal Release
Please read and check the boxes, certifying the following:
As an OUT HEALTH, INC. volunteer, I understand that my services are offered without anticipation of any financial compensation or reimbursement. I agree to abide by any rules and direction provided to me by my supervisor(s) at OUT HEALTH, INC. and I will immediately report misconduct, injury, or incident to my supervisor(s). I give my permission and consent to OUT HEALTH, INC. and any agency affiliated with OUT HEALTH, INC. to use, print, copy, publish, and reproduce any and all videotapes, audio tapes, photographs, films, negatives, prints reproductions, and likeness of any kind now or hereinafter of myself made by OUT HEALTH, INC. for advertising, publicity, display, or any purpose whatsoever without fees to be paid to myself and/or any child listed on this application. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied. I certify that all information provided on this application is true, and I authorize the OUT HEALTH, INC. to contact my education, employment and/or references referred to in this application to attain any relevant information regarding my desire and ability to volunteer. If this application is for a minor, please include the name and contact email/phone number of a parent or guardian over the age of 18, and have that person check this box whereby certifying the accuracy of the information submitted on this Volunteer application. Parent/Guardian Contact Info