North Clackamas Lunch Buddy Program
Volunteer Application Form
6031 SE King Road
Milwaukie, OR 97222
First Name:
Middle Name:
Home Address:
Last Name:
City:
E-mail:
State:
Home Ph#:
Have you ever been involved
as a Lunch Buddy before?
Date of Birth:
Zip:
Work Ph#:
Cell Ph#:
Do you have any children? If so,
how many?
YES
NO
What ages?
Employer:
Employer's Address:
Occupation/Title:
City:
State:
Zip:
Since your 18th birthday, have you ever been arrested for, charged with, or convicted of a crime including
felonies, misdemeanors, and serious traffic violations (i.e. DUI, drug, child abuse or sex related crimes)?
YES
NO
*If yes, please describe in detail the offense(s) and date(s), include City and State:
(Affirmative answer to the question listed above will not automatically disqualify you.)
What other youth organizations have you worked for or been involved with as a volunteer?
Organization Name & Location
Please complete all 3 pages.
Dates Involved
Position or Type of Involvement
Volunteer Application-page 1 of 3
Match Preferences
This form will be used to help make an appropriate Lunch Buddy match. Please respond to the following
questions.
1.
Please circle grade preference of child you would like to mentor:
1 st
2 nd
3rd
4th
5th
Boy?
Girl?
2.
What are some of the activities you see yourselves doing together?
3.
Do you see yourself with a talkative child, or someone more on the quiet side?
4.
What kind of personality traits might be challenging for you?
5.
Students come from a wide range of cultural, racial, religious, and lifestyle backgrounds.
Are there issues or concerns that would make a relationship uncomfortable or difficult for
you?
6.
Which of these words best describe you?
Flexible
Good Listener
Patient
Shy
Athletic
Outgoing
Musical
Punctual
Creative
Other
7.
Do you have any special interest, hobby, talent or skill that you would like to share with a
child?
8.
Do you speak any languages other than English? If so, which language?
9.
Do you have any physical limitations we should be aware of?
Volunteer Application- Page 2 of 3
Personal References
Please submit three personal references who have known you for at least 1 year. These references
cannot be a relative or live in the same household. Letters will be mailed to each so please provide a
complete address.
1. Employer or Business Reference:
Address:
City:
Day Phone #:
Evening Phone #:
State:
Zip:
Email:
2. Community Reference:
Address:
City:
Day Phone #:
Evening Phone #:
State:
Zip:
Email:
3. Personal Friend:
Address:
City:
Day Phone #:
Evening Phone #:
State:
Zip:
Email:
Name and phone number of person to contact in case of emergency
__________________________________________________________________________
Do you have any medical conditions the Lunch Buddy Program should be aware of in case of
an emergency?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I certify that all statements contained herein are true and complete.
Signature
Date
Volunteer Application- Page 3 of 3