Volunteer Application Step 1 of 3 33% General InformationFields marked with an asterisk * are required.Name* First Last Middle name Maiden Name N/A if not applicableAny known alias Gender* Male Female Date of Birth* Month Day Year Email Address Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Business Phone*Cell Phone* QualificationsFields marked with an asterisk * are required.Current job responsibilities and schedule:*Previous work experience:*Previous volunteer experience:*Special interests, hobbies, languages, and skills:*Position interested in: Why would you like to volunteer as a worker with children and/or youth?*What qualities do you have that would help you work with children and/or youth?*What days are you available?*select all that apply: Sunday Monday Tuesday Wednesday Thursday Friday Saturday When are you available on Sundays?* Morning Afternoon Evening When are you available on Mondays?* Morning Afternoon Evening When are you available on Tuesdays?* Morning Afternoon Evening When are you available on Wednesdays?* Morning Afternoon Evening When are you available on Thursdays?* Morning Afternoon Evening When are you available on Fridays?* Morning Afternoon Evening When are you available on Saturdays?* Morning Afternoon Evening Can you make the necessary duration commitment to this volunteer role?* Yes No Would you be available for periodic volunteer training sessions?* Yes No Do you have your own transportation?* Yes No Do you have a valid driver's license?* Yes No Drivers License Number Issuing State Do you have liability insurance? Yes No List policy limits and name of carrier. If you were to witness abuse or neglect against a child or vulnerable adult, would you be able to report the incident to your supervisor? Yes No Statement of DisclosureFor questions 1-6 provide explanations for “Yes” responses. Knowingly providing false information will be grounds for disqualification of application.Fields marked with an asterisk * are required.1. Have you ever been convicted of any crime against children or any other persons?* Yes No 1. "Yes" Explanation*2. Do you have any pending charges against you?* Yes No 2. "Yes" Explanation*3. Have you been convicted of the possession, use, or sale of drugs within the last 7 years?* Yes No 3. "Yes" Explanation*4. Have you been convicted of any other misdemeanors or felonies?* Yes No 4. "Yes" Explanation*5. Has your driver’s license been suspended or revoked within the last seven years?* Yes No 5. "Yes" Explanation*6. Have you lived in a state other than New York in the past 7 years?* Yes No 6. List States*Please read thoroughly and sign Confidentiality Agreement and Verification that this Information is accurate. I affirm that all information provided on this form is accurate to the best of my knowledge.* Yes No I understand that a photocopy or facsimile of this signed document shall be considered as valid as an original.* Yes No I understand that the information from this review process may be shared with the Pastor of Sarah Jane Johnson Memorial United Methodist Church.* Yes No I hereby consent, to and authorize the Conference to conduct the following background checks: criminal records, sex offender registry, and child abuse registry.* Yes No I am willing to have pertinent information shared with Sarah Jane Johnson Memorial United Methodist Church and its ministries. I release the Conference, its employees or volunteers from any and all liability associated with conducting the above background checks.* Yes No I affirm I have no objection to these checks.* Yes No I promise to keep in confidence any information shared with me about children, other volunteers, or any other confidential information shared in the provision of my work. This includes the taking of photographs, discussing personal information, and family information.* Yes No References*Please list three personal references (people not related to you by blood or marriage) and provide a complete address and phone information for each. References are confidential. Reference NameAddressDaytime PhoneEvening PhoneEmailRelationship to reference Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
