You may submit this form online, or download the Volunteer Application (.pdf) and mail or fax to: MADD Pennsylvania, 2323 Patton Road, Harrisburg, PA 17112. Fax: (717) 540-4824.
Name*
Address:
City:
State:
County:
Zip Code:
Home Phone*
Cell Phone:
Work Phone:
Email*
Date of Birth:
Preferred Method of Contact:
Best Time to Contact:
a.m. p.m.
* required fields
What brings you to MADD?
Have you had a personal drunk driving victimization experience? Yes No
Did this victimization result in: Injury Bereavement Both?
Please describe:
Have you ever been convicted of a drunk driving offense? Yes No
At what times are you interested in volunteering? (check all that apply)
Weekdays Weekends Days Evenings Flexible Special Events
Do you have access to an auto you can use for volunteer work? Yes No
In which counties are you willing to volunteer?
What other volunteer activities are you now, or have you previously been involved with?
Is there a particular group with whom you are interested in working? (check all that apply)
Youth Teens Adults Senior Citizen Staff Victims Male Female One-to-one On your own No preference Other
Is there a particular type of volunteer work you are interested in? (check all that apply)
Victim advocacy* Public awareness Fundraising Legislative initiatives Local or state leader* Public speaking Youth programs* Special events Court monitoring Community outreach General office assistance No preference Other * background check required
Hobbies, Interests and Skills
Things you do not like to do:
Do you speak languages other than English? Spanish Other
Current Occupation
Educational Background
Please list the name and number of someone we may contact as a personal reference.
Phone Number*
MADD Pennsylvania will never rent, sell or otherwise give away the personal information of you or your friends - we respect your privacy!
