Planned Parenthood of Houston and Southeast Texas: Survey

PPLAMD Volunteer Application

Please fill out the following information.

If you have previously registered, please to prepopulate your information.

Name:

First Required	Middle Required	Last Required

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Country:

Phone Number: Required

Gender: Required

Date of Birth: Required

Month

Day

Year

Email Format:

Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required	5 to 60 characters
*	Password: Required	5 to 20 characters
*	Repeat Password: Required

*2.

Ethnicity

Are you multi-lingual? If so, what languages do you speak?

	Spanish
	Vietnamese
	Chinese
	Japanese
	French
	German
	Arabic
	Italian
	American Sign Language
	Other

*4.

BACKGROUND & EDUCATION: What is your education? (University, degree, area of study, etc.)

Pleast list any organizations you are a member of:

Please list any organizations where you volunteer:

(Maximum response 255 chars, approx. 5 rows of text)

*7.

WORK HISTORY: As part of our background check, may we contact the employers listed below?

If not, please explain briefly.

Current employer

10.

Current position

11.

Dates of employment

12.

Employers telephone number

13.

Current job duties

(Maximum response 255 chars, approx. 5 rows of text)

14.

Previous employer

15.

Previous position

16.

Dates of employment

17.

Previous employer telephone number

18.

Previous job duties

(Maximum response 255 chars, approx. 5 rows of text)

19.

Please check preferred volunteer location(s):

	New Orleans
	Baton Rouge

*20.

Please check time(s) available

	Morning (7-11)
	Afternoons (12-4)
	Evenings (5-7)
	All Day
	Weekends

21.

Volunteer Opportunities

	Public Affairs
	VOX (campus outreach)
	Clinic advocacy
	Administrative Support (Clinic and Admin)
	Planned Parenthood Young Leaders
	Health Fairs
	Local business outreach
	Event support and planning

*22.

Why are you interested in volunteering for Planned Parenthood?

23.

Do you know anyone who currently works for or volunteers with PPLAMD? (please list)

24.

Have you ever volunteered for a Planned Parenthood before? if yes, please state when and where, and any details you would like to add:

*25.

REFERENCES: Please list the name, address, telephone and email address of two persons you know, your relationship to them, and how long you have known them. Your first reference:

(Maximum response 255 chars, approx. 5 rows of text)

26.

Your second reference:

*27.

In case of emergency, who should we contact? (name, relationship & phone number please)

*28.

Have you been convicted of a felony or misdemeanor other than a minor traffic violation in the last 7 years?

29.

If you answered yes, please explain below. Conviction is not an automatic disqualification. All circumstances will be looked into when making a determination.

*30.

I agree with the written statement below, certifying my application is accurate, and giving permissions.

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Copyright Planned Parenthood of Houston and Southeast Texas 3601 Fannin Street, Houston, Texas 77004, phone 713-522-6363, email pphset@pphouston.org The information provided on this Web site is for the visitors' personal education only and is not a substitute for medical care. Get accurate information about sexual and reproductive health care, and visit a qualified health care provider for personal medical evaluation, counseling, and services. To be connected to our nearest clinic call 1-800-230-PLAN Printer Friendly Version