Planned Parenthood Southeastern Pennsylvania

Volunteer Application

*Denotes required fields

*Name:
*Address:
*City:
*State:
*Zip:
*Email:
*Home Phone:
*May we leave a message?	Yes No
Work Phone:
May we leave a message?	Yes No
Cell Phone:
Occupation
Employer

*Are you over 18 years of age?	Yes No
(Applicants under 18 years of age need parental consent to volunteer with PPSP)
Are you a student?	Yes No Full Time Part Time
What school?
Do you need community service hours for school?	Yes No
How many hours?
When must they be completed by:
*Briefly explain why you are interested in volunteering for PPSP and what you hope to offer
Do you have language translation skills?	Yes No
If yes, which language(s)?
Special training/skills:
Have you ever worked/volunteered for Planned Parenthood before?	Yes No
If yes, when and where:

Work preferred (check all that apply-see brochure for details):
Administrative Assistant
Community Outreach/Education
Development Assistant
Health Center Services
Internship/Externship
Department:
Patient Escort
Public Affairs/Advocacy
Street Squad
Clinic Advocate
Letter Writing Group
Lobbying
Cocktails for a Cause
Other:

Health Center volunteers are required to submit proof of MMR, TB and Hepatitis immunizations.
If you would like to volunteer in a Health Center, which location(s) do you prefer? (check all that apply)
1144 Locust Street-Health Center
1144 Locust Street-Surgical Center
Elizabeth Blackwell Center (1211 Chestnut St.)
Castor Ave.-Northeast Philadelphia
Pottstown
Collegeville
Norristown
St. David's
Upper Darby
Media
Comly Road-Northeast Philadelphia
West Chester
Coatesville

What hours are you available?
Approximately how many hours per week can you volunteer?
How long of a commitment can you make to PPSP?	3 months 6 months A year or more

Current Or Previous Volunteer Experience
Where:
Position:		How long:

Where:
Position:		How long:

Please list two professional references (If you are a student, one of these should be a teacher , advisor or school administrator, and the other should be a former employer, volunteer coordinator, church group leader, etc.):
*Name:
*Phone:
*Relationship:

*Name:
*Phone:
*Relationship:

Please provide an emergency contact:
Name:
Phone:
Relationship:

* Since your 18th birthday, have you been convicted of any criminal offense?	Yes No
If yes, please briefly explain:

Age Group	Gender	Ethnicity
Under 18	Male	African-American
18-25	Female	Asian/Pacific Islander
26-40	Other	Caucasian/White
41-60		Hispanic/Latino
60+		Native American
		Other

Yes! I want to join the Planned Parenthood Action Network and be kept up to date on legislative happenings! Please send me more information.

By applying, I acknowledge that I will be spending time at Planned Parenthood and providing services to Planned Parenthood as a volunteer or intern. I understand that as a volunteer or intern I will not be entitled to any pay for the time that I spend at PPSP. If in the future I wish to be employed by Planned Parenthood, then I understand that I will be required to apply for work through PPSP's Human Resources Department.

Check here to accept conditions.