Volunteer Application

Volunteer Application

Join our team! Please fill out the form below and we’ll consider you for a volunteer position.

Name (First and Last) (required)

Address (required)

County (required)

City (required)

ZIP Code (required)

Phone Number (XXX-XXX-XXXX) (required)

Phone Number Type (required)

Fax Number

Email Address (required)

Sex (required)

Date of Birth (YYYY-MM-DD) (required)

Spouse's Name

 White, Non-Hispanic Black or African-American Native American/Alaska Native Asian Hispanic/Latino Other


How Did You Hear About CLAIM
 Volunteermatch.com This website Friend or relative Newspaper or newsletter Employer CLAIM Volunteer/Staff (please list name in "Specify Other" box) AmeriCorps Member (please list name in "Specify Other" box) Other

Specify Other

Positions I Am Interested
 Counselor Leader in Outreach Administrative Support Interest Specialist Mentor

CLAIM volunteers cannot work for insurance companies, have an insurance license and/or sell insurance for at least one year prior to volunteering. A person cannot potentially receive any financial gain from becoming a CLAIM volunteer counselor.

Are you currently working in the insurance industry?(required)

If no, have you in the past 12 months?(required)

If yes, what were your responsibilities?

Occupation (If retired, please note "Retired" and former occupation)(required)


Community Service

Reasons for Wanting to Volunteer (required)

Would you be willing to make a minimum commitment of six hours/month for six month?(required)

Language Skills

Have you ever been convicted of a felony? (A background check will be completed during training)(required)


Please list three references (Name and Phone Number).

Reference One (required)

Reference Two (required)

Reference Three (required)