Volunteer Application Date:
Volunteer Interest: (Check all that apply)	Mentoring Individual Group Agency

CONTACT INFORMATION

Full Name:	Home Phone:	( )
Current Address:	Cell Phone:	( )
E-mail Address:
How long have you lived at the above address? years months
List previous address if you have lived at the current address less than two (2) years
Street Address:
City:	State:	Zip:

Family Status: Single Married
Emergency Contact Name: (If applicable)	Emergency Contact #:	( )	Relationship:

EMPLOYMENT INFORMATION (Current)

Employer:	Your Title:
Address:
Contact #:	( )

EMPLOYMENT INFORMATION (Previous)

(List previous employer if at current employment less than two (2) years.)

Employer:	Your Title:
Address:
Contact #:	( )

THIS SECTION IS REQUIRED IF YOU WILL SUPERVISE OR TRANSPORT YOUTH.
SS #:	- -	Date of Birth:
Do you have a valid driver’s license? No Yes
Driver’s License #:	State Issued:	Expiration Date:
Auto Insurance Carrier:	Insurance Expiration Date:

EDUCATION INFORMATION

School(s) Attended:	Degree Received:
Degree Received:
Degree Received:

VOLUNTEER EXPERIENCE

Agency Name:	Dates of volunteer work:
Contact Name:	( )	Contact #:	( )
Did you work directly with youth when volunteering at this agency?	No Yes If yes, briefly describe.
Describe other volunteer responsibilities and reason for leaving, if applicable:

Agency Name:	Dates of volunteer work:
Contact Name:	( )	Contact #:	( )
Did you work directly with youth when volunteering at this agency?	No Yes If yes, briefly describe.
Describe other volunteer responsibilities and reason for leaving, if applicable:

Agency Name:	Dates of volunteer work:
Contact Name:	( )	Contact #:	( )
Did you work directly with youth when volunteering at this agency?	No Yes If yes, briefly describe.
Describe other volunteer responsibilities and reason for leaving, if applicable:

CURRENT VOLUNTEER INTEREST

Why are you interested in volunteering with this agency?

HISTORY INFORMATION

Do you have any history of alcohol or drug abuse?	No Yes
If yes, briefly explain including any treatment received.

Have you ever been convicted of a misdemeanor or felony?	No Yes
If yes, briefly explain including offense and conviction dates.

Have you ever been convicted of a traffic violation?	No Yes
If yes, briefly explain including offense and conviction dates.

OTHER INFORMATION YOU WOULD LIKE TO ADD REGARDING THE ABOVE HISTORY SECTION.

REFERENCES

List four references (not relatives) who have known you for at least one (1) year. Include complete mailing addresses.

Full Name:	Home Phone:	( )
Address:	Other #:	( )
E-mail Address:
Relation:

Full Name:	Home Phone:	( )
Address:	Other #:	( )
E-mail Address:
Relation:

Full Name:	Home Phone:	( )
Address:	Other #:	( )
E-mail Address:
Relation:

Full Name:	Home Phone:	( )
Address:	Other #:	( )
E-mail Address:
Relation:

I certify that all information on this application is true to the best of my knowledge.

I agree for a criminal background check to be conducted. In the event I supervise or transport youth a driver’s licenses check will also be conducted. Furthermore, I authorize the agency to inquire about my previous/present volunteer and work experience and to contact the references listed above.

I understand that any false statements, withheld information or negative feedback from reference(s) will be reason(s) to disqualify me from volunteering with this agency.

Volunteer Name (Sign):	Date: _______________________

Volunteer Name (Print): __________________________________________

FOR AGENCY USE ONLY

Date References checked:
Staff Checking References: