Evening (Please specify)       

Number of hours willing to give per week   per month

 Short-term: Less than 3 months                   Long-term: More than 3 months

If you are volunteering to meet requirements for school, court, etc., please list:

Program:  Contact Person:

No. of required hours:   Phone:   Completion date: 

Please describe your reasons for wanting to volunteer with the Alliance of AIDS Services-Carolina.

Please describe any work limitations/disabilities/other information we may need to know:

III. Volunteer Areas of Interest:  Please indicate your area of interest(s) by checking the appropriate boxes

Wake County

Downtown Office:

Administrative Assistance – various office projects to support staff.

Health Fairs - provide information, education, & referrals about HIV/AIDS to those visiting Alliance display. 

Safer Sex Kits– Put together safer sex kits containing condoms, lubricants and safer sex information.

Street Outreach - Provide HIV/AIDS risk reduction education to individuals in a street outreach setting.

Thursday Night HIV Testing – greet people who come to get tested for HIV/AIDS.

Hustead House:

Appointment driver – drive residents to daytime medical appointments.

Office assistance – provide staff with miscellaneous office support.

Companion – visit with residents in the house and/or accompany house residents on recreational activities.

Meal Provider – cook meals for house residents.

Lawn and Garden –maintains house lawn and garden area.

Under One Roof:

Food Drive – conduct community food drives and/or pick up/drop off food.

Food pantry stocking – clean, organize and stock shelves in food pantry.

Food pantry shopper – assist staff with shopping, loading and unloading of food pantry stock.

Front desk support – answers phone, checks shoppers in & out of food pantry, schedules appointments.

Translators – translate materials into Spanish & French; work with Bilingual Advocate to plan events for

     Spanish-speaking clients.

Durham County

Office support– provide staff with miscellaneous office support.

Food pantry stocking – clean, organize and stock shelves in food pantry.

Food pantry shopper – assist with shopping, loading & unloading of food pantry stock.

Food Drive – conduct community food drives, pick up/drop off food.

Orange County

Appointment driver – drive residents to daytime medical appointments.

Companion – visit with residents in the house and/or accompany house residents on recreational activities.

Meal Provider – cook meals for house residents.

Lawn and Garden –maintains house lawn and garden area.

Triangle Wide

Faith Ministry Care Team Member – provide non-judgmental practical care & emotional support to a client.

Faith Ministry Assistance – work with staff to plan interfaith programs, activities and events for clients.

Special Events

Special Events – assist with special events such as

       Drag Bingo   AIDS Walk and Ride   Evening with Friends   Works of Heart Art Auction

Special Projects

       Black Church Week of Prayer for the Healing of AIDS   World AIDS Day

III.  Background Information

We request the following information not as a violation of your privacy, nor because we hold any blanket

suspicion of potential volunteers. We do so because of our dedication and commitment to our clients, and

their families, including children. All service-based organizations must take reasonable precautions in

appointing those who work directly with clients and their families, especially when dealing with such

sensitive issues as HIV and AIDS. This is a necessity  in today’s world, and we would be remiss should we

not carry out this responsibility. The information provided below will be kept confidential, and will only be

shared with key staff persons as deemed appropriate by our director. It is for your protection as well as that

of our staff , clients, their families, and children.

Have you ever been convicted of any crime other than minor traffic violations?                       Yes No    If yes, please explain. 

Have you ever been convicted for the use or sale of illegal drugs?     Yes No    If yes, please explain.

What has been your experience with alcohol and/or drugs?                       Other None    If Other - Please explain.

Have you ever been diagnosed with any serious mental illness or disorder, not including mild episodic/situational

depression or anxiety?                         Yes No    If yes, please explain.

Other than the above, are there any facts or circumstances involving you personally that are pertinent to our securing

volunteers who are dedicated and committed to the safety and welfare of our staff, clients, their families and their

children?                       Yes No    If yes, please explain.

Agreement:  I certify that the information provided is true and accurate.  I give permission for you to conduct a driving and/or

criminal background check if necessary.

Electronic Signature of Volunteer:                        Date:   January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31