SMP Volunteer Application Form

Contact Information

Applicant Information

2. Please tell us about your work experience, including paid and volunteer positions. If you are currently employed, please list your current job first. Use the remaining space to describe other work experiences (paid or volunteer) that relate in any way to the SMP volunteer position.

If you will be driving to and from SMP events, you will need to provide a copy of your driver's license and proof of insurance. We will collect this information at a later point in the screening process.

Medicare Provider Number (If Medical Provider)

Interest in the SMP Program

Note: To ensure the safety of our clients, volunteers, and the communities we serve, applicants will be asked to consent to a criminal record check. (This information will be kept confidential.)

Authorization and Certification

I certify that the information I provided in this application is true, complete, and accurate to the best of my knowledge. I also authorize the Hawaii SMP to contact the references named below with regard to my application to become an SMP volunteer. I also authorize the persons referenced to provide information in connection with my application, and release them from any liability in regard to it.


Please provide three references, including at least one professional or work reference, that are not related to you and who we may contact to ask about your qualifications (if the reference is a supervisor or co-worker, please note the organization for which the individual works).

After reading the SMP Volunteer Role Descriptions, I am interested in volunteering for:
Assisting with Administration Distributing Information Staffing Exhibits Making Group Presentations One-on-One Counseling Handling Complex Interactions

Consent to Perform Driver’s License and Records Check

The contents of this form address the following VRPM policies: 1.7, 1.8, 3.31, 3.34, and 3.44.

I hereby give my consent to the Hawaii SMP program to perform a driver's license and records check as required for the volunteer position for which I have applied.

I understand that I do not have to agree to this records check, but that my refusal may exclude me from consideration for SMP volunteer positions that involve driving, including the roles of distributing information, making group presentations, and staffing exhibits.

I understand that the Hawaii SMP program will limit the information it collects to that needed to determine my suitability for particular types of volunteer work and will keep all such information confidential.

Driver’s License and Records Check Information
Secured by Paubox Encrypted Email - HITRUST CSF Certified