Seacoast Science Center, Inc. Tax ID# 02-0526488


Youth Volunteer Application Thank you for your interest in becoming an SSC Youth Volunteer (ages 13-17)! Please allow 2-3 weeks for your confidential application to be reviewed and to be contacted to an interview. If you have any questions, please contact Laura Bahl, Volunteer Coordinator, at l.bahl@sscnh.org. Ages 18 and over, please complete the Adult Volunteer Application.
Today's date: *
Volunteer First Name: *
Volunteer Last Name: *
Address 1: *
Address 2:
City: *
State: *
I am interested in becoming a: *	Youth Volunteer Counselor in Training
Zip: *
Primary Phone: *
Alternative Phone:
Email: *
Date of Birth (MM/DD/YYYY): *
________________
Parent/Guardian #1
Parent #1 First Name: *
Parent #1 Last Name: *
Parent #1 Phone: *
Parent #1 Email: *
Parent/Guardian #2
Parent #2 First Name:
Parent #2 Last Name:
Parent #2 Phone:
Parent #2 Email:
________________
Please indicate why you would like to volunteer (include special interests): *
________________
Volunteer Experience
Place of service:
Volunteer Position:
________________
Special Considerations
Please indicate if you have any medical conditions we should be aware of:
Will your volunteer service require the assistance of an aide? If yes, please explain.
Name of Aide or service:
Aide's Phone:
________________
Emergency Contacts
Contact #1 (first, last name): *
Relationship #1: *
Contact #1 Phone: *
Contact #2 (first, last name):
Relationship #2:
Contact #2 Phone:
________________
If you do join as a volunteer, please ask your parent/guardian to fill out the V olunteer Waiver and Liability Form. Please bring the signed form to the Center on or before your first shift. Authorization to Obtain Information (to be filled out by parent or guardian): I. the undersigned, authorize any agent of the Seacoast Science Center, to obtain information regarding my child's employment, volunteer experience, or personal reference in connection with my application for volunteer service. Such information will be held in confidence in accordance with agency guidelines:
*	I agree I do not agree
Parent/Guardian name: *
Date: *
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

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