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:

Postal Code

Home Phone:

Work Phone:

Fax:

Email:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relationship:

Date of Birth:

Month	Day	Year

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:

Volunteer OpportunitiesPlease check areas of interest

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:
Preschool
Primary grades K-3
Grades 3-5
Middle grades 6-8
High school grades 9-12

Please select days you are available to volunteer:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (limited)
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?

Application Submitted!