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Volunteer Application
Step
1
of
5
20%
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Date of Birth
Month
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Day
1
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Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2002
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1936
1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Desired Volunteer Job & Location
Emergency Contact
First
Last
Emergency Contact Phone
Are you 18 years old or older?
(Required)
Yes
No
Have you ever been convicted of a felony?
(Required)
No
Yes
Please Explain:
(Required)
Address on Driver's License
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address (if not Indiana resident for past six (6) months)s
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
References
Reference #1
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Relationship
(Required)
Reference #2
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Relationship
(Required)
Photo Release
(Required)
By checking the box below, you acknowledge that you have read and agree to the statement:
I agree to release without limitation, all claims to photographs, video images, audio recordings or information about me in regard to my volunteer experience. I agree these may be reproduced for use by LifeStream Services Inc. for print and online promotions, videos, reports, printed materials, and other publicity as warranted by LifeStream Services Inc. I also agree all claims for compensation or damages are hereby waived.
Confidentiality & Non-Disclosure Agreement:
(Required)
By checking each box, you acknowledge that you have read each statement and agree to these statements:
Nondisclosure. I hereby acknowledge and agree the confidentiality of all personal information to which I gain access is protected by state and federal law. I further acknowledge and agree that I will not use or disclose any personal information at any time or for any reason whatsoever in a manner which violates any state or federal law, including without limitation, the Privacy Rules.
I acknowledge and agree any violation of this agreement may result in LifeStream Services Inc. imposing immediate termination of contract.
General. This agreement may not be amended except in writing and signed by both parties hereto. No failure or delay in exercising any right, power or remedy hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any other right, power or remedy. This agreement constitutes the entire agreement between the parties hereto relating to the subject matter hereof, and supersedes any prior or contemporaneous verbal or written agreements, communications and representations relating to the subject matter hereof.
Voluntary Participation & Execution:
(Required)
By checking the box below, you acknowledge that you have read and agree to the statement:
I acknowledge and willing agree to serve as a volunteer for LifeStream Services Inc. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and LifeStream Services Inc. I sign it of my own free will.
Signature
(Required)
Background Check Authorization
Background Check Authorization
(Required)
By checking each box, you acknowledge that you have read each statement and agree to these statements:
I hereby authorize LifeStream Services, Inc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment processes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to LifeStream Services, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.
I further authorize LifeStream Services, Inc. to do an annual and/or random background checks for the purpose of evaluating my continued employment.
I understand pursuant to the federal Fair Credit Reporting Act, LifeStream Services, Inc. will provide me a copy of any such report if the information contained in it is, in any way, to be used in making a decision regarding my employment and/or continued employment with LifeStream Services, Inc. I further understand that such report will be made available to me prior to any such decision being made.
I hereby release LifeStream Services, Inc., and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.
Signature
(Required)
Request for Reference
Reference Authorization
(Required)
I authorize LifeStream Services, Inc. to contact my current and any former employers and references in order to investigate my past performance and other information contained on my application. I further authorize my current and former employers to respond to the questions set forth by LifeStream Services, Inc. and its designated representatives.
By checking the box below, you acknowledge that you have read and agree to the statement:
Signature
(Required)
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