Volunteer Application



OFFICE USE ONLYDate received: / / .Location:□ Jefferson□ Junction City□ The Club□ Plover□ Almond/BancroftBackground check complete: / / .Volunteer Application Form **The information requested is necessary to perform a background check before your application can be considered for volunteer opportunities. Your application WILL NOT BE CONSIDERED unless all fields are completed.**Name: FORMTEXT ?????DOB: FORMTEXT ?????Social Security #: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Home Phone: FORMTEXT ?????Work Phone: FORMTEXT ?????Email FORMTEXT ?????Where did you learn about our volunteer opportunities? FORMTEXT ?????Are you seeking to volunteer in order to satisfy court-ordered community service? FORMTEXT ?????DEMOGRAPHIC INFORMATION (optional) This information is used for statistical data in applying and/or reporting for grants.I am: FORMCHECKBOX Male FORMCHECKBOX FemaleEthnicity: FORMCHECKBOX Caucasian FORMCHECKBOX African American FORMCHECKBOX Hispanic FORMCHECKBOX Asian FORMCHECKBOX Hmong FORMCHECKBOX Native American FORMCHECKBOX Other FORMTEXT ?????SKILLS AND EXPERIENCE What is your educational background/occupation? FORMTEXT ?????In which way are you most comfortable interacting with youth? (Physical Activity/Sports; Mental Activities/Board games; Arts and Crafts/cooking & crafts; Technological activities/Computers) FORMTEXT ?????What are your hobbies? FORMTEXT ?????Do you have any past or present volunteer experience? If yes, please describe. FORMTEXT ?????Why do you want to volunteer at the Boys and Girls Club?INTEREST INVENTORY Please check the area(s) that interest you. Check as many or as few as you like! I would enjoy: FORMCHECKBOX Music Leader/Assistant-Which type(s)? FORMTEXT ????? FORMCHECKBOX Tutoring-Which subjects? FORMTEXT ????? FORMCHECKBOX Sports Coach/Assistant-Which sport(s)? FORMTEXT ????? FORMCHECKBOX Arts and Crafts Activity FORMCHECKBOX Instructor/Assistant Helping a Child Use a Computer FORMCHECKBOX Listening to a Child Read FORMCHECKBOX Playing Board Games FORMCHECKBOX Assisting with Fundraising FORMCHECKBOX Leading a Recreational Activity FORMCHECKBOX Acting as a Mentor for Teens FORMCHECKBOX Leading a Discussion Group FORMCHECKBOX Assisting with Office and Clerical Work FORMCHECKBOX Chaperoning a Field TripActivities not listed above that I am interested in: FORMTEXT ?????Continued….PREFERENCES IN VOLUNTEERINGMembers of the Boys & Girls Clubs are ages 6 to 18 depending on the site. Which age groups would you most enjoy working with? (check as many as you like)? FORMCHECKBOX 6 to 8 years old FORMCHECKBOX 9 to 10 years old FORMCHECKBOX 11 to 12 years old FORMCHECKBOX 13 to 15 years old FORMCHECKBOX 16 to 18 years old FORMCHECKBOX No preference / all agesAVAILABILITYThis section will help determine the best days and times for your volunteer activity. Please mark all days and times you will be available to volunteer. (The Boys & Girls Club is not open on weekends)MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Are there any physical limitations or are you under any course of treatment that might limit your ability to perform certain types of work? FORMTEXT ?????ADDITIONAL INFORMATION AND RELEASE FOR BACKGROUND CHECK (Please check the applicable response) Have you ever been convicted of a criminal offense? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been convicted of child abuse or neglect? FORMCHECKBOX Yes FORMCHECKBOX NoHas your license ever been suspended or revoked? FORMCHECKBOX Yes FORMCHECKBOX NoAre there any other facts or circumstances involving you or your background that would call into question your being entrusted with the supervision, guidance and care of young people? FORMCHECKBOX Yes FORMCHECKBOX NoPlease use an additional sheet of paper to explain any “Yes” response)CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT I certify that all information submitted in this volunteer application, interview, or other information is true and complete, and that I have not knowingly withheld, nor will I withhold, any information that would effect my application or volunteer employment. I understand the employer is under no obligation to consider or reconsider my application at anytime and that acceptance of this application does not constitute an offer of volunteer employment and that falsification of this application will be grounds for elimination from further consideration, or if employed, for dismissal at anytime. FORMTEXT ????? FORMTEXT ?????Signature DateDuring the application process and at any time during the tenure of my volunteer employment with the Boys & Girls Club of Portage County, I give permission to the Boys & Girls Club of Portage County to obtain records that would, or may have any bearing on volunteering at the Boys & Girls Club of Portage County. These records may include local, state and criminal record checks as well as any records in which I am a complainant, victim, defendant, or mentioned. FORMTEXT ????? FORMTEXT ?????Signature Date ................
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