Bright Futures Application Form

Bright Futures Application Form

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Birthdate +

School Name

(NOTE: Parental Consent Form is required for Volunteers under 18 years of age.)

Emergency Contact Name *

Phone Number *

Have you volunteered with us before?

No	Yes (provide when and where) Yes (provide when and where)

Who is your community service designee at high school? (Include name, phone, email address)

What do you hope to gain from your volunteer experience?

How soon would you like to start volunteering?

What position(s) are you interested?

Have you spoken to a volunteer site coordinator about the position?

No	Yes (include name and department) Yes (include name and department)

Is there any expertise or special experience you would like to offer? Please explain.

Times available to volunteer (select all that apply) *

Flexible

Morning

Afternoon

Evening

How many hours can you commit? *

Project-based

Semester

Hours per week Hours per week

For our record, have you ever been convicted or had adjudication withheld in a criminal offense, or are there any criminal charges pending against you? (Note: A conviction or adjudication withheld will not automatically disqualify you from volunteering with Pinellas County.) *

Yes

Acknowledgement Statement *

I certify that all statements made in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

Your Name *

Today's Date * +

* Your e-mail address is required to submit this form. E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead, contact this office by telephone (727-464-8477) or in writing, via the United States Postal Service to this address:

Pinellas County Volunteer Services

400 S. Fort Harrison Ave, 1st Floor, Suite 111
Clearwater, FL 33756

County Website	School Coordinator
Social Media (Pinellas Volunteers)	Other Student
County Employee	Social Media (Pinellas Careers)
Other Other