PPKM :: Planned Parenthood of Kansas & Mid-Missouri

Thank you for you interest in volunteering for Planned Parenthood of Kansas & Mid-Missouri. The information you provide on this form will help us determine the most satisfying volunteer opportunity for you within Planned Parenthood. Please complete all sections.

Today’s Date Thursday, March 11, 2010

Contact Information
	First:	Middle:	Last:
	Street Address:	City:	State:	Zip:
	Phone (Day):	Evening:	Cell:
	Best way to contact you? Day Evening Cell Email
	Email Address
	Are you under the age of 18? Yes No (Applicants under the age of 18 must obtain parental consent to volunteer.)
	Would you like to be placed on the Planned Parenthood Action Network e-mail list? YesNo
	MaleFemale (optional)
Have you ever volunteered with PPKM before? YesNo

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Volunteer Interests - Plead read through our Volunteer Opportunities and mark which positions most interest you.
Some positions may require interviews and/or background checks.

		Event Volunteer -Assist in day-of-event activities -Become an event committee member -Assist in planning and organizing events		Administrative Volunteer -Prepare supporter mailings -Provide general clerical support -Assist with special projects		Advocacy & Outreach Volunteer -Join a Reproductive Health Action Team in Kansas or Missouri -Participate in visibility events, rallies & tabling events -Assist organizers in phone banking, data entry & special advocacy projects
		Education Member -Advocate for education & health center services at community events -Co-facilitate sex-education workshops -Help with classroom preparation & instruction		Health Center Volunteer -Make and verify patient appointments -File lab reports and charts -Provide office support

Availability - Please indicate days and times of availability.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Afternoon
Evening

Desired Length of Commitment (please select one)

	On-call (as needed for projects).
	Community service hours (hours required each week)
	Short term & seasonal (less than 6 months) hours per week
	Long term (6+ months) hours per week

Location - Please indicate the location(s) in which you would like to volunteer.
Note: Some opportunities are not available in all areas.

Administration Office:
Overland Park (Suzanne E. Allen Center)

Health Center Locations:
Hays	Independence	South KC	North KC
Jefferson City	Overland Park	Lawrence	Midtown KC (Patty Brous Center)
Columbia	Warrensburg	Wichita

Kansas Health Action Team Locations:		Missouri Health Action Team Locations:
Johnson & Wyandotte County		Midtown KC
Wichita		Northland
		Eastern Jackson County
		Columbia

Education / Skills
    High School Graduate     College Graduate     Current Student - grade level:
    Bilingual / Multilingual - language(s):
    Biliterate / Multiliterate - language(s):
    Special training or skills

    Community or Volunteer activities


Have you ever been convicted for a violation of any federal, state, county, or municipal law, regulation, or ordinance? (Do not include misdemeanor or traffic violations, etc.)
YesNo

Questions - Please respond to the following.

    1. How did you hear about PPKM's volunteer program?


    2. Please state briefly why you are interested in volunteering for PPKM.


    3. What do you know about Planned Parenthood and what we do?


Personal References - Please give the name, telephone number and relationship of two people we can contact for a personal reference.
    1.
    2.

Emergency_Contact_Information - Please indicate the name, telephone number and relationship of someone we can contact in case of emergency.
    1.

I certify that all information provided on this application is true and complete. I authorize PPKM to verify the information provided. I understand that omission or falsification of information is grounds for refusal of my volunteer service or for my dismissal from volunteer service upon discovery.