Personal Information - Samaritan House



1128395-4312Volunteer Application00Volunteer ApplicationPersonal InformationName: ____________________________________________________________________________________________________Address: ________________________________________________________ City: ____________________________________State: _______________ ZIP: _____________________ Work phone: _____________________________________Cell phone: ____________________________________________Email: _____________________________________________________________________________________________________Work and Education ExperiencePlease select the option that best applies to your current employment status:74295266700525399026670407225536195192786030480 Currently employed currently between jobs Student I am retiredCurrent job position/title: ________________________________________________________________________________Current employer: ________________________________ Duration of employment: From: _________ To: _______ Does your employer allow for time off volunteering? ______Yes _____ NoEducation:Please indicate below the school you are attending, program of study/degree you are seeking, and approximate graduation date. Are you currently a student? ______Yes _______No College/University: _______________________________________ Program of Study: _________________________ Anticipated Degree: ________________________________________Graduation Date: ___________________________ Please list any other degrees you have:_________________________________________ Degree ______________________________________College/University_________________________________________ Degree ______________________________________College/UniversityReferencesPlease list 2 non-family reference whom we might contact:Name: ________________________________________________Phone:_____________________________________________Name: ________________________________________________Phone: ____________________________________________Availability (some volunteer opportunities require a minimum time commitment) Please indicate your availability below:Weekdays 9 AM till 5 PMWeekends 9 AM till 5 PM____ Monday _____Tuesday _____Wednesday _____Thursday _____Friday______Saturday ______SundayWeeknight and evenings 5 PM till 11 PMWeekend nights/evenings 5 PM till 9 PM_____ Monday _____Tuesday _____Wednesday _____Thursday _____Friday______Saturday ______SundayFor students only:Are you volunteering as part of a class project or requirement? If so please state the class or project requirments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Skills and InterestsPlease indicate your experiences/skills:____Advocacy/Civil Rights____Children’s Programs (Art Therapy/Child Care)____Community Outreach/Education____Counseling____Event Planning/Coordinating____Fundraising____Finance____Grant Writing____Intake____HTML/Web Design____Life Skills (stress management, self-sufficiency skills, job readiness, resume)____Maintenance____Social Media____Volunteer RelationsOther: ______________________________________________________________________________________________________________________________________________________ Please include any certifications or trainings relevant to volunteering with us: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.As a volunteer you will be working with clients of many different ethnic and socioeconomic backgrounds. Clients may have values and beliefs quite different from your own. Please describe why this will or will not present a difficulty or adjustment for you as a volunteer. ____________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Volunteer Opportunities Please help us match you with assignments you would enjoy. Please indicate the types of volunteer services that are of interest to you (check all that apply).24 Hour Crisis Hot LineAdministrative DutiesChildren’s DepartmentCourt Companion ProgramDevelopment/Fundraising Donations SorterEducation and OutreachFinance_______Housing InspectorLandscaping/Maintenance Research or Individual ProjectsShelter ShopperSocial Media/MarketingSpecial Events_____TransportationAre there specific tasks that you are unable to perform due to physical limitation or personal preference? YesNo __ If yes, please explain: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Have you volunteered with us before? Yes ______ No _____ . If Yes, please explain why you stopped volunteering. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.What are your goals as a volunteer? School CreditsInternshipSeasonalResume Enhancement Corporate SponsorshipContribution to CommunityCourt Ordered Church OutreachSocialization Other: _________________________________________674798-27813000Background VerificationHave you ever been convicted of a criminal offense? YesNo Please explain:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Have you ever been charged with neglect, abuse or assault? YesNo Please explain: _______________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________.Has your driver’s license ever been suspended or revoked in any state? YesNo Please explain: _______________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________.Do you use illegal drugs?YesNo Please explain: _______________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________.Emergency Contact Information:Name: _______________________________________________________ Relationship:_________________________________Phone: __________________________________ Email Address____________________________________________________How did you hear about us?Social Media (Facebook, Twitter, Instagram, Web page) ______ Referred by friend/volunteer ______ School/Teacher ______ Community Forum ______ TV/Radio ______ Newspaper _____ Church _____ Work _____ Other: _____Terms and AgreementsOur volunteer program may need to do one or all of the following background screenings (Criminal Background, Child Protective Service Record, Sexual Offender Record and Driving Record). If so, all information, as well as all information on this application will be kept confidential and measures will be taken to protect your privacy. To do the screenings social security number and date of birth will be needed.I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief. I further consent for Samaritan House to obtain additional information necessary to process my application. This may include but is not limited to employment verification, references and background checks. (Please note your refusal may exclude you from consideration from volunteering with Samaritan House).Name:____________________________________________________ Today’s Date:__________________________________Social Security Number: _________________________________________Date of Birth:______________________________Thank you for your interest in Samaritan HouseMission: To foster personal safety, self-sufficiency and personal growth in adults and their children through freedom from domestic abuse and homelessness. ................
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