CRWRC Disaster Response Services



133350-889000 SERVICELINK VOLUNTEER APPLICATION FORM (One application per person)Note: Your application is the first step in finding an appropriate place for you to serve as a volunteer. We will do our best to help you find that place. However, completing this form does not guarantee placement, nor does it obligate you to accept an assignment if offered. Please TYPE or SELECT appropriate answers. Date: FORMTEXT ?????Name (as on passport): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? First Middle LastOccupation: FORMTEXT ????? FORMCHECKBOX Present FORMCHECKBOX Previous Education: Degree/diploma obtained: FORMTEXT ????? Area of Study: FORMTEXT ?????Status: FORMCHECKBOX Employed FORMCHECKBOX Unemployed FORMCHECKBOX Semi-retired FORMCHECKBOX Retired FORMCHECKBOX Student FORMCHECKBOX Other FORMTEXT ?????Permanent Home Address: Street number and name: FORMTEXT ?????City; State/Prov; Zip/PC: FORMTEXT ????? 6. Alternate Address: Dates at this address: from: FORMTEXT ????? to FORMTEXT ?????Street number and name: FORMTEXT ?????City; State/Prov; Zip/PC: FORMTEXT ????? 7. Communication: Home Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Work Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? ext. FORMTEXT ????? Mobile Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Email: FORMTEXT ?????8. Church membership: Church Name: FORMTEXT ?????Classis or District: FORMTEXT ?????City; State/Prov: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Email: FORMTEXT ?????9. Person(s) to contact in case of emergency: Name: FORMTEXT ?????Relationship: FORMTEXT ????? Home Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Mobile Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Email: FORMTEXT ????? Name: FORMTEXT ?????Relationship: FORMTEXT ????? Home Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Mobile Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Email: FORMTEXT ????? 10. References: List two persons other than relatives and pastors. A. Name: FORMTEXT ?????Street address: FORMTEXT ????? City; State/Prov; Zip/PC: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Email: FORMTEXT ????? Relationship to you: FORMTEXT ????? B. Name: FORMTEXT ?????Street address: FORMTEXT ????? City; State/Prov; Zip/PC: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Email: FORMTEXT ????? Relationship to you: FORMTEXT ?????11. Assignment preferences (check all that apply): A. North America OpportunitiesB. International Opportunities FORMCHECKBOX Group Opportunity FORMCHECKBOX Group Opportunity FORMCHECKBOX Individual (attach resume) FORMCHECKBOX Individual Opportunity (attach resume) Desired Destination: FORMTEXT ????? Desired Destination: FORMTEXT ?????12. Recruitment Information: Who/What most influenced you to apply for this volunteer work? Please select one. FORMDROPDOWN FORMTEXT ?????13. Photo consent Do you grant permission for use of any photo taken of you for promotional purposes? FORMDROPDOWN 14. Availability FORMCHECKBOX ONLY ONE assignment. Specify preferred dates: From FORMTEXT ????? to FORMTEXT ????? FORMCHECKBOX Several assignments. FORMCHECKBOX Local ongoing assignment. FORMCHECKBOX Have already been assigned to a project:Name of Project: FORMTEXT ????? Dates of Project: From FORMTEXT ????? to FORMTEXT ?????15. Why are you volunteering to work with this Christian organization? FORMTEXT ?????16. Skills and Experience: According to the following guidelines, please rank ONLY those skills that apply to you, by writing the number in the space provided. 1 – Can work only with close guidance of a skilled person. 2 – Can work alone, but with some guidance. 3 – Can work confidently and independently in this area. 4 – Skilled in this area, and can guide or teach others. 5 – Am Licensed/Certified in this area or field. FORMTEXT ??? Accountant/Bookkeeper – 701 FORMTEXT ??? Agriculturalist – 642 FORMTEXT ??? Assistance to Elderly – 501 FORMTEXT ??? Assistance to Handicapped - 502 FORMTEXT ??? Attorney - 702 FORMTEXT ??? Auto/Truck Mechanic - 604 FORMTEXT ??? Business Manager - 605 FORMTEXT ??? Carpenter - 403 FORMTEXT ??? Child Care (certified) - 504 FORMTEXT ??? Child Care (uncertified) - 503 FORMTEXT ??? Clergy - 606 FORMTEXT ??? Commercial Artist - 603 FORMTEXT ??? Community Organizer - 632 FORMTEXT ??? Computer Programmer - 712 FORMTEXT ??? Computer/Data Processor - 713 FORMTEXT ??? Concrete Worker - 409 FORMTEXT ??? Electrician - 415 FORMTEXT ??? Electronics Technician - 624 FORMTEXT ??? Engineer - 629 TYPE: FORMTEXT ????? FORMTEXT ??? Farmer - 607 TYPE: FORMTEXT ????? FORMTEXT ??? Fundraiser - 621 FORMTEXT ??? General Assistant - 433 FORMTEXT ??? Grant Writer - 619 FORMTEXT ??? Heavy Equipment Operator - 608 FORMTEXT ??? Journalist - 627 FORMTEXT ??? Manager/Supervisor - 609 FORMTEXT ??? Medical Technologist - 630 FORMTEXT ??? Musician - 610 FORMTEXT ??? Nurse – 611 FORMTEXT ??? Nurse's Aide – 612 FORMTEXT ??? Nutritionist - 640 FORMTEXT ??? Office Support - 601 FORMTEXT ??? Painter - 421 FORMTEXT ??? Photographer - 613 FORMTEXT ??? Physician - 614 TYPE: FORMTEXT ????? FORMTEXT ??? Plumber - 423 FORMTEXT ??? Prayer Support - 512 FORMTEXT ??? Researcher - 623 FORMTEXT ??? Salesperson - 631 FORMTEXT ??? Social Planning - 510 FORMTEXT ??? Social Worker - 633 FORMTEXT ??? Speaker/Presenter - 620 FORMTEXT ??? Teacher - 617 FORMTEXT ??? Therapist: PT/OT – 634 FORMDROPDOWN FORMTEXT ??? Truck Driver (Valid CDL) - 618 FORMTEXT ??? Videographer - 616 FORMTEXT ??? Web Page Designer - 714 FORMTEXT ??? Overseas Work Experience - 643 PLACE(S): FORMTEXT ????? FORMTEXT ??? Other - 999 SPECIFY: FORMTEXT ????? FORMTEXT ??? Spanish (speak) - 9011 FORMTEXT ??? Spanish (read) - 9012 FORMTEXT ??? Spanish (write) - 9013 FORMTEXT ??? Spanish (translate) - 9014 FORMTEXT ??? French (speak) - 9021 FORMTEXT ??? French (read) - 9022 FORMTEXT ??? French (write) - 9023 FORMTEXT ??? French (translate) - 9024 FORMTEXT ??? American Sign Language - 9100 FORMTEXT ??? Other language - 9071 SPECIFY: FORMTEXT ?????As an image bearer of God, who desires to help my neighbors far and near to become self-sufficient in meeting their own needs, I am committed to the Christian faith and willing to support the Christian Reformed Church in North America’s (CRCNA’s) mission which states:As people called by God, we gather to praise God, listen to Him and respond. We nurture each other in faith and obedience to Christ. We love and care for one another as God’s people. We commit ourselves to serve and to tell others about Jesus. We pursue God’s justice and peace in every area of life.To the best of my knowledge, and recent physician’s report (within the past 2 years), I am capable of performing the duties that match my skills and interests. I am emotionally stable, flexible, adaptable and creative in order to work in demanding and diverse situations. I understand this information will be shared as needed to ensure safe, appropriate assignments. FORMCHECKBOX Limitations, if any (such as epilepsy, diabetes, dizziness, heart conditions, etc.) Please specify: FORMTEXT ????? FORMCHECKBOX I am willing to have a complete physical exam and/or appropriate immunization as required for a specific assignment. FORMCHECKBOX I understand that funding varies from one opportunity to another. I may have to cover some or all of my own expenses. FORMCHECKBOX I am willing to provide a police background check if required. FORMCHECKBOX I certify that the information contained in this application is true and accurateU.S. DISCLAIMERUnless agency staff is notified by phone or mail, volunteers may receive future mailings for volunteer opportunities and/or CRCNA programs and campaigns.CANADIAN PRIVACY STATEMENTThe information provided by the Applicant in this form will be used to assess the suitability of the Applicant for placement in available volunteer roles and, when possible, to place volunteers in demographically appropriate roles. This information will also be used to update Christian Reformed Church constituency records, which includes mailing lists pertaining to the Christian Reformed Church and its agencies/ministries. The information provided by the Applicant in this form will only be used for these purposes and will not be disclosed to third parties except in furtherance of these purposes or as required by law. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Electronic Signature of Applicant Date Electronic signature of parent or legal guardian, if applicant is under 18 years oldPlease send completed application form to the ServiceLink office.volunteer@orServiceLink3475 MainwayPO Box 5070, Stn LCD1Burlington, ON CANADA L7R 3Y8 THANK YOU! ................
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