YWCA of the Coulee Region Volunteer Application

Transcription

1 YWCA of the Coulee Region Volunteer Application NAME: Last First Middle Preferred name: ADDRESS: ADDRESS: HOME TELEPHONE: ( ) WORK TELEPHONE: ( ) CELLULAR TELEPHONE: ( ) I prefer to receive calls at: Home Work Cell BEST TIME TO CALL: PREFERRED FORM OF CONTACT: Phone Doesn t Matter Spouse or Partner Name: CHILDREN (List names and ages of all children): OTHER HOUSEHOLD MEMBERS (List names, ages, and relationship): IN CASE OF AN EMERGENCY, NOTIFY: Relationship: Phone: (home and cell) (work) VOLUNTEER EXPERIENCE (List current/most recent first; use additional paper if needed) ORGANIZATION/AGENCY DATES SUPERVISOR DUTIES

2 EDUCATION (Circle highest year completed for each, and list dates attended.) High School Dates: College Dates: Graduate School Dates: Highest degree earned: Major field of study: Are you presently attending school? Yes No If Yes, name of school and program: EMPLOYMENT INFORMATION (List current/most recent first; use additional paper if needed) I am: Employed Un-employed Retired Student Place Employed: Dates of Employment: Position/Title: Full Time Part Time Brief Description of Duties: Place Employed: Dates of Employment: Position/Title: Full Time Part Time Brief Description of Duties: Place Employed: Dates of Employment: Position/Title: Full Time Part Time Brief Description of Duties: Check which area you would like to volunteer in. Economic Empowerment YWCA Child Care Center Racial and Social Justice Programming Advocacy and Mentoring Special Events/Projects I need more information Housing CASA for Kids Program 2

3 How did you find out about the YWCA Volunteer Opportunities? Availability Please check the times you are usually available for a volunteer assignment (please write more specific times underneath if needed): Sunday Monday Tuesday Wednesday Thursday Friday Saturday Notes on Availability/what date are you able to start volunteering? I want to volunteer because... Please list any strong interests, knowledge, areas, hobbies, certifications, unique experiences or special skills which you could offer as a volunteer: Please indicate which areas you have training/experience: Juvenile Court Social Work Child Welfare Child Development Foster Care Group Home Mental Health Residential Treatment Drug/Alcohol Human Services Law, Police Other Please describe your experience in the above area(s): 3

4 Please list memberships in clubs and organizations: Language(s) that you speak: Transportation Information *We conduct driving records checks when volunteers indicate interest in programs that involve transporting participants/clients. Do you own an automobile? Yes No Driver License #: Expiration Date: If No, do you have access to an automobile? Yes No If you drive a car, provide the following information about your auto insurance. (This information is needed for client transportation.) Auto Insurance Company: Policy #: Expiration Date: REFERENCES (One personal reference and two volunteer or employment related references who can assess your employment, intern/volunteer experiences, educational experiences, or provide a character reference.) GIVE INDIVIDUAL S NAME / COMPLETE MAILING ADDRESS / TELEPHONE 1. NAME: PHONE: RELATIONSHIP: ADDRESS: 2. NAME: PHONE: RELATIONSHIP: ADDRESS: 3. NAME: PHONE: RELATIONSHIP: ADDRESS: **ONE ADDITIONAL PERSONAL REFERENCE REQUIRED FOR CASA VOLUNTEERS ONLY** 4. NAME: PHONE: RELATIONSHIP: ADDRESS: 4

5 YWCA of the Coulee Region Release of Information To Whom It May Concern: I hereby authorize a representative of the YWCA to conduct an investigation of my background in conjunction with official duties. The investigation may include police records, traffic transcripts, character references, insurance verification, and child protective services reports. I further authorize any law enforcement agency to conduct a criminal records check and to release the results of said criminal records check to the YWCA. I also authorize La Crosse County Health and Human Services to release the results of their child protective services check to the YWCA. I execute this release with full knowledge and understanding that the information obtained is for official use of the YWCA. I further understand that if the background checks provide proof of conviction or charges pending for a felony or misdemeanor involving any criminal offense that would pose risks to women and children or the YWCA s credibility, the applicant will not be considered as a volunteer for the YWCA. I understand that refusal to sign this release for above named checks will result in a rejection of the YWCA application. I have read the above waiver and release statement and fully understand what rights I am waiving by signing this document. NAME: Last First Full Middle DATE OF BIRTH: Month/Day/Year GENDER: DRIVER S LICENSE #: SOCIAL SECURITY #: RACIAL/ETHNIC IDENTIFICATION: OTHER NAMES BY WHICH YOU HAVE BEEN/OR ARE NOW KNOWN BY: Have you ever been convicted for a violation other than a minor traffic offense? Yes No (Report all convictions - past and present. Convictions may not automatically disqualify you) If yes, what was your offense? Date convicted? City/State of conviction: End date of probation/parole or court jurisdiction: Are you currently involved in a court matter in Wisconsin or any other jurisdiction? Yes No Do you have a close friend or family member currently under any type of court jurisdiction, and/or in any correctional/placement/institution/facility? Yes No If yes, please list name(s) and relationship(s): Current Phone Number: Current Address: List where you have lived the past five (5) years other than La Crosse County: Are you now or have you ever been involved with child protection or social services authorities in La Crosse County or any other jurisdiction? Yes No If yes, list dates and circumstances(use additional paper if needed): I declare that the preceding information is true and correct to the best of my knowledge. I understand that this release will remain in effect for one year from the date noted below. Signature Date 5

6 YWCA of the Coulee Region Electronic Photo/Video Release Name Birth date Address Phone I understand the following to be true: The release of any photo images of me during my experiences is my choice and not a part of any mandated programming of the YWCA I agree to the YWCA using any photo or video images of me taken during my programming experience with them on display for marketing purposes or promotion of YWCA activities The YWCA cannot control the use of these images nor be held responsible for the direction of a third party use after they have been on display either in a presentation or on the Internet I am not allowing my image to be shown reciprocal services rendered from the YWCA of the Coulee Region Electronic media may include an Internet presence There is no monetary gain from the YWCA of the Coulee Region for my participating in my image being used I, agree to talk to the media about my experiences within the YWCA of the Coulee Region s programming. Thank you for allowing the YWCA to use your image in communicating experiences about the YWCA of the Coulee Region. Your sharing will help to let others know that there is help available to them. We appreciate your telling your story to help others. 06/20/2017 MKH Phone: (608) ext info@ywcalax.org 6