1. I would like to be a part of Safe Kids Portland Metro to support the mission of preventing injuries to children in Oregon through
education, advocacy, enforcement, and environmental change.
NO
EDUCATION
DRIVERS LICENSE #: STATE OF ISSUE: DATE OF BIRTH:
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION:
HIGH SCHOOL FRESHMAN
HIGH SCHOOL SOPHOMORE
HIGH SCHOOL JUNIOR
HIGH SCHOOL SENIOR
COLLEGE FRESHMAN
COLLEGE SOPHOMORE
COLLEGE JUNIOR
EMPLOYER:
IF YES, PLEASE EXPLAIN:
BEST WAY TO CONTACT YOU?
EMPLOYER INFORMATION
WORK ADDRESS:
CRIMINAL HISTORY
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
OCCUPATION: LENGTH OF EMPLOYMENT:
YES
COLLEGE SENIOR
POST GRADUATE
PERSONAL INFORMATION
SAFE KIDS Portland Metro
Volunteer Membership Form Lead Agency
WORK PHONE #: FAX:
HOME PHONE #: E-MAIL:
MAILING ADDRESS:
STREET ADDRESS (if different):
NAME: OTHER NAMES (AKA):
CITY/STATE/ZIP:
CITY/STATE/ZIP:
PLEASE LIST PREVIOUS VOLUNTEER EXERIENCE:
HIGH SCHOOL OR COLLEGE NAME:
DEGREE EARNED (if any):
WHY DO YOU WANT TO BECOME A SAFE KIDS VOLUNTEER?
Revised 6/24/16

2. I would like to be a part of Safe Kids Portland Metro to support the mission of preventing injuries to children in Oregon through
education, advocacy, enforcement, and environmental change.
APPLICATION RECEIVED ON:
APPROVED? YES NO
PARENT OR GUARDIAN
RETURN TO:
FOR COALITION USE ONLY
Safe Kids Portland Metro
c/o American Medical Response
1 SE 2nd Ave
Portland, OR 97214
FOR QUESTIONS CALL:
American Medical Response
Community Education Department
(503) 736-3460
SIGNATURE:
SIGNATURE:
DATE:
DATE:
Other
AGREEMENT
If my application is approved, I agree to attend Safe Kids Portland Metro events and support the
misison of injury prevention to children. I further agree that I will not knowingly misrepresent Safe Kids. I
realize that Safe Kids Portland Metro may, at its discretion, revoke my "volunteer status" at any time that it
is in the best interest of Safe Kids to do so.
I understand that this application is subject to a criminal violation and record check conducted by
appropriate law enforcement agencies. Safe Kids Portland Metro reserves the right to decline the
application based on information provided by the record check.
Bike & Wheeled Sports Safety
Child Passenger Safety - Kids Buckle Up
Fall Prevention
Poison Prevention
Water Safety
I AM INTERESTED IN SUPPORTING INJURY PREVENTION EFFORTS IN THESE AREAS (check all that apply):
Revised 6/24/16