Boston Partners in Education

VOLUNTEER REGISTRATION FORM

**If you are experiencing difficulties submitting this form, please print it out and fax it to Barbara Harris at 617-482-0617**

Title:
First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:	State: Zip:
Home Phone:
Work Phone:
Fax:
Email:
Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact Relationship:

Date of Birth:
Gender:	M F
Ethnic Origin (optional):	Other:
School/Employer Name/Organizational Affiliation:

Work Status:	Parent of BPS Student?
Do you have a physical condition that should be considered in selecting the right school assignment for you? If so, please specify?:

Please provide two references (business or personal):
Name:	Phone:
1.
2.
Volunteer Opportunities Please check areas of interest. Subject area(s):

	Math
	Literacy
	Read Aloud
	One to one tutoring/mentoring
	Classroom assistance (Kindergarten level only)
	Career/enrichment presentation (Middle & High School levels only)
	Other

Please select the grade level(s) you are interested in working with:

Please select days you are available to volunteer:

Please list the hours you are available:

Is a car available to you? Yes No

What subway/bus lines are convenient for you?

Is there a neighborhood/school/program you prefer to serve in?

What volunteer work have you done in the past?

Are you fluent in a language other than English? Please specify:

Note your favorite hobbies, pastimes, instruments you play, etc.:

How did you learn about Boston Partners in Education?