volunteer application - Children's Home Society
volunteer application - Children's Home Society
volunteer application - Children's Home Society
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CHILDREN’S HOME SOCIETY<br />
VOLUNTEER APPLICATION<br />
Name: ________________________________________________________ Male ___ Female ____<br />
Address: __________________________________________________________________________<br />
__________________________________________________________________________________<br />
<strong>Home</strong> Phone _____________________________ Work Phone _____________________________<br />
Fax No. _______________________________ E-mail Address _____________________________<br />
Age: ___ 16-20 ___ 31-40 ___ 51-60 ___ 71-80 Birthday ______________<br />
___ 21-30 ___ 41-50 ___ 61-70 ___ 80+<br />
* Must be at least 21 years of age to work directly with CHS children<br />
Current or former occupation: ________________________________________________________<br />
Employer _____________________________________ Position ______________________<br />
Please answer the following question by circling yes or no:<br />
YES NO 1. Does/has your employment involve(d) the education and/or care of children<br />
If yes, please describe._________________________________________________<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
Other work experience: ______________________________________________________________<br />
_________________________________________________________________________________<br />
Special training/skills: _______________________________________________________________<br />
_________________________________________________________________________________<br />
Education: (circle last year completed) Elementary: 5 6 7 8 High School: 9 10 11 12<br />
College: 1 2 3 4 Graduate Work: ___________________<br />
Field of study or interest: ______________________________________________________________
Emergency contact: _______________________________________ <strong>Home</strong> # _________________<br />
Relationship to you: _______________________________________ Work # _________________<br />
Hobbies/Interests: __________________________________________________________________<br />
Previous <strong>volunteer</strong> experience (please include any experience with children/youth).<br />
1.__________________________________________________________________________<br />
2.__________________________________________________________________________<br />
3.__________________________________________________________________________<br />
Skills/Interests I would like to share: ____________________________________________________<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
Skills/Interests I would like to develop: __________________________________________________<br />
__________________________________________________________________________________<br />
__________________________________________________________________________________<br />
Volunteer preferences: __ short-term projects __ special events/projects __ a scheduled assignment<br />
AVAILABILITY FOR VOLUNTEERING<br />
Morning<br />
Afternoon<br />
Evening<br />
Mon Tues Wed Thurs Fri Sat Sun<br />
How much time do you want to <strong>volunteer</strong> ________________________________________________<br />
How did you hear about <strong>Children's</strong> <strong>Home</strong> <strong>Society</strong>'s <strong>volunteer</strong> program _________________________<br />
__________________________________________________________________________________<br />
Why I wish to <strong>volunteer</strong> at <strong>Children's</strong> <strong>Home</strong> <strong>Society</strong>:<br />
Please complete the "Volunteer Opportunites" sheet and enclose with your <strong>application</strong>.<br />
REFERENCES
Please list three persons not related to you whom you have known for at least one year. Choose from the<br />
categories listed below; no more than one per category.<br />
___ current employer ___ instructor ___ character<br />
___ former employer ___ clergy ___co-worker<br />
___ <strong>volunteer</strong> supervisor<br />
1. Name (Mr. Ms.) _____________________________________ Relationship ___________________<br />
Address _____________________________________________________________________<br />
<strong>Home</strong> Phone ____________________________<br />
Work Phone ________________________<br />
2. Name (Mr. Ms.) _____________________________________ Relationship ___________________<br />
Address _____________________________________________________________________<br />
<strong>Home</strong> Phone ____________________________<br />
Work Phone ________________________<br />
3. Name (Mr. Ms.) ____________________________________ Relationship ___________________<br />
Address _____________________________________________________________________<br />
<strong>Home</strong> Phone ____________________________<br />
Work Phone ________________________<br />
4. Name (Mr. Ms.) ____________________________________ Relationship ___________________<br />
Address _____________________________________________________________________<br />
<strong>Home</strong> Phone ____________________________<br />
Work Phone ________________________<br />
In addition to references and central registry, it may also be necessary to complete a criminal background<br />
check and be finger printed.<br />
________________________________________________________ ______________________<br />
Your Signature<br />
Date<br />
Please return this completed <strong>application</strong> to: Volunteer Coordinator<br />
<strong>Children's</strong> <strong>Home</strong> <strong>Society</strong><br />
PO Box 1749<br />
Sioux Falls SD 57101-1749
DISCLOSURE<br />
DISCLOSURE - Must be a clear and conspicuous written disclosure to the consumer before the report is<br />
obtained, in a document that consists solely of the disclosure. Sample language is shown below:<br />
As part of our hiring background and investigation, we may obtain consumer reports or prepare an investigative<br />
consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify<br />
your employment history. It may also include, but not be limited to, credit information reports, criminal history<br />
reports and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u)<br />
as amended, before we can seek such reports, we must have your written permission to obtain the information. You<br />
have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the<br />
investigation. You are also entitled to a copy of your Rights Under the Fair Credit Reporting Act.
AUTHORIZATION TO RELEASE INFORMATION<br />
I, __________________<br />
Last Name First Name Middle Name<br />
Current Address<br />
Addresses for the Past Seven Years: (include street, city, state, zip code)<br />
Dates Lived Here<br />
Dates of Residence:<br />
Date of Birth Other Names Used (including maiden name) Years Used<br />
Social Security Number Driver's License # State<br />
Email address (may be used for official correspondence)<br />
do hereby authorize verification of all information in my employment <strong>application</strong> from all sources of employment, education, motor<br />
vehicle, financial history, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and<br />
wage records, etc. or any part thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether the said<br />
records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all<br />
persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively by<br />
IntelliCorp Records, Inc for identification purposes and for the release information which will be considered in determining any<br />
suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment <strong>application</strong>,<br />
any supplements to it and in any interview in the knowledge that they will be relied upon in considering my <strong>application</strong> for employment.<br />
I agree to provide additional information that may be requested to process my employment <strong>application</strong>. I authorize without reservation,<br />
any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned information. This authorization is valid<br />
during the course of my employment to the extent permitted by law.<br />
**I hereby do _______do not_________ authorize you to contact my current employer for Employment and Reference Verifications<br />
(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the<br />
Employment/Reference Section of your <strong>application</strong>.)<br />
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all<br />
information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which<br />
IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.<br />
I understand and agree that any omission, false statement, misleading statement, or answer made by me on my <strong>application</strong> or any<br />
supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.<br />
_____________________________________________ _______________<br />
Printed Name Applicant Signature Date<br />
CALIFORNIA, OKLAHOMA, and MINNESOTA RESIDENTS ONLY: If you are a current California, Oklahoma, or<br />
Minnesota resident and would like to request a copy of your Consumer Report or Investigative Consumer Report, please check<br />
the box. This report may include character and reputation information obtained through personal interviews.<br />
DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND.<br />
LEGAL ADVICE SHOULD BE SOUGHT FROM YOUR ATTORNEY. WE MAKE NO CLAIMS,<br />
PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS, OR ADEQUACY<br />
OF THE INFORMATION CONTAINED HEREIN. WE MAKE NO WARRANTY THAT THIS<br />
FORM IS APPROPRIATE FOR YOUR PARTICULAR NEEDS.
DSS-CP-594-12/00 (CHS Replica 11/2005)<br />
DECLARATION OF PRIOR CRIMINAL CONVICTION AND MILITARY HISTORY<br />
As required by SDCL 26-6-14.5 for employment, residence or presence in a child welfare<br />
agency, this declaration must be completed and retained in the employee/provider/<strong>volunteer</strong> file.<br />
For foster homes licensed by DSS, a copy of the form should be submitted with DCI and FBI<br />
fingerprint cards to the Office of Child Protection Services, 700 Governors Drive, Pierre, SD<br />
57501-2291.<br />
The following comprises a complete history of prior criminal convictions for:<br />
Name: _________________________ Soc Sec #: ________________ Birthdate: ___________<br />
Crime Convicted Of Date of Conviction Sentence or Disposition<br />
Do not leave this section blank. If “none”, please state so.<br />
Crimes are to include all felonies, misdemeanors, traffic citations, etc.<br />
______________________ __________________ _____________________________<br />
______________________ __________________ _____________________________<br />
______________________ __________________ _____________________________<br />
______________________ __________________ _____________________________<br />
The following is a complete history of military service for _______________________________.<br />
(Name)<br />
Branch of Service Dates of Service Type of Discharge<br />
Do not leave this section blank. If “none”, please state so.<br />
_________________________ ___________________ _______________________<br />
_________________________ ___________________ _______________________<br />
I hereby declare and affirm under penalty of perjury that the foregoing information is true and<br />
correct to the best of my knowledge and belief.<br />
Date (Month, Day, Year)<br />
Agency Return Address<br />
_________________________________________ Children’s <strong>Home</strong> <strong>Society</strong> of SD<br />
(Signature)<br />
( ) Black Hills Children’s <strong>Home</strong><br />
( ) Children’s Inn<br />
_________________________________________ ( ) Sioux Falls Children’s <strong>Home</strong><br />
Street Address and/or PO Box Number P. O. Box 1749<br />
Sioux Falls, SD 57101-1749<br />
_________________________________________<br />
City State Zip Code