Caswell County Partnership for Children

Volunteer Application

Applicant’s Name: _________________________________  Date of Application:  _______________

Home Phone _______________  Cell Phone: ___________   E-Mail Address____________________

Address_________________________ City____________ Zip_________

Emergency Contact: _________________________ Relationship: _______________

Work Phone: ______________ Home Phone: ________________ Cell: ________

Employer: __________________________________ Phone: (___) ____________

Your Position: _____________ Employed From/To: __________________

Schedule: __________________ May we call you at work? Yes___ No___

Name of last High School Attended: __________________ State_____ County_______

Did you graduate? Yes___ No____ Did you receive a GED? Yes____ No____

Education Beyond High School:

Institution/City/State          Dates Attended          Degree          Month/Year          Major

If you are under the age of 18, please list your age: _____

Why are you interested in volunteering? _____________________________________

Please list previous, relevant volunteer experience such as clubs, professional organizations, church or service organizations:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check the area(s) that you would be interested in volunteering:

___ Teaching a skill or a hobby to a child                                      ____ Assisting with clerical duties

___ Tutoring/Assisting with Homework                                        ____Assisting with group activities        

___ Chaperoning Fieldtrips                                                          ____ Assisting with Community Outreach

___ Providing Child Care during workshop/meeting                  ____ Other (please specify): ___________

___ Donating professional services, i.e. medical, dental, legal, artwork, etc.

Can you make a commitment to this program for at least one-year?     � Yes   � No

If no, please explain_______________________________________________________

When are you able to volunteer?  

 - Days of the Week:  _______________________________________________________

 - Times of Day:  ___________________________________________________________

Do you have Transportation? Yes___ No___

Drivers license number and state: DL#__________ State_____ Date of Expiration______________

Auto Insurance Carrier: ____________ Insurance Expiration Date___/___/____

Have you ever received a traffic violation? Yes___ No ___ If yes, please explain_______________

________________________________________________________________________________

________________________________________________________________________________

Have you ever been convicted of a misdemeanor or felony involving children or violence?

Yes ___ No____

If yes, state offenses and the date of conviction__________________________________________

________________________________________________________________________________

________________________________________________________________________________

List three professional references (not relatives or friends) who have known you for at least one year.  Include complete mailing addresses and phone numbers.  The references should be able to attest to your character, skill, and dependability, as well as, your experience or ability to work with children.  If you have experience with youth as a volunteer, please be sure to list as a reference your supervisor(s) from that experience.

1. Name______________________________________       Organization/Title:  __________________

Address: ____________________________ City: ______________ State:_______

Home Phone: (___) ____________ Work Phone: (___) __________________

How long have you known this reference and through what relationship:  _______________________

__________________________________________________________________________________

2. Name______________________________________       Organization/Title:  __________________

Address: ____________________________ City: ______________ State:_______

Home Phone: (___) ____________ Work Phone: (___) __________________

How long have you known this reference and through what relationship:  _______________________

__________________________________________________________________________________

3. Name______________________________________       Organization/Title:  __________________

Address: ____________________________ City: ______________ State:_______

Home Phone: (___) ____________ Work Phone: (___) __________________

How long have you known this reference and through what relationship:  _______________________

__________________________________________________________________________________

I certify that all the information included on this application is true to the best of my knowledge. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or will be reason to disqualify me from serving as a Caswell County Partnership for Children Volunteer, whenever it may be discovered.

I hereby authorize the Caswell County Partnership for Children to contact, obtain, and verify the accuracy of information included in this application. I hereby give my permission to contact the references listed above. I also understand that a criminal background check will be conducted. Furthermore, I authorize the Caswell County Partnership for Children to inquire about my previous/present volunteer and work experience. I understand and agree that a negative reference may result in me not becoming a Caswell County Partnership for Children volunteer.  I also hereby release from liability the Caswell County Partnership for Children and its representatives for seeking, gathering, and using such information to make decisions and all other persons or organizations for providing such information.

Signature: _________________________________              Date: _________________________