First Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Business or Organization

Daytime Phone Number

Evening Phone Number

Cell Phone Number

Email Address *

Are you certified in Basic First Aid/CPR?
 Yes No

Are you 18 years or older?
 Yes No

Are you willing to attend an Orientation/Training meeting prior to volunteering?
 Yes No

How did you hear about the Egan Warming Center?

Please list any skills or volunteer/professional experience relevant to working with people.

Please indicate an area of interest...
 Food & Hospitality
 Set-Up & Security
 Resource & Support
 Guest Intake
 Phone/Email Work

Please indicate the shift(s) you will most likely be available to work:
 Flexible Schedule...
 SHIFT ONE: 6:00 PM - 10:30 PM
 SHIFT TWO: 10:00 PM - 6:00 AM
 SHIFT THREE: 5:30 AM - 9:00 AM

Please list months and/or days you are NOT available (For example: from Nov. 15-Mar.1):

Do you have a site preference?
 Ebbert (Springfield)
 Seventh Day Adventist (Springfield)
 First Christian (Downtown Eugene)
 St. Mary's (Downtown Eugene)
 Valley Covenant (Eugene)
 St. Matthews Episcopal
 Trinity
 Youth Site
 Church of the Resurrection (South Hills)
 Central Lutheran (Campus)
 Lane Community College (Campus)

Additional Comments: