minn-ia-kota girl scout council - Girl Scouts - Dakota Horizons

VOLUNTEER APPLICATION
Volunteers are appointed on the basis of their ability to perform and
willingness to accept the Girl Scout Promise and Law.
For MS (office) use only:
Area ________________
SU _________________
Troop # _____________
‣ Girl Scouts – Dakota Horizons conducts background checks on its volunteers who come in
contact with the girls or money. Information is confidential and will be used and retained only as
authorized by law.
‣ Any volunteer appointment is contingent upon the completion and review of a background check.
‣ Any questions left blank may result in incorrect information and may delay the processing of
your form.
‣ Written approval must be received from Girl Scouts—Dakota Horizons before assuming any role
or meeting with girls.
‣ Return completed form, within 30 days to your Membership Specialist or mail to: Girl Scouts –
Dakota Horizons, ATTN: Membership Assistant, 1101 S Marion Rd, Sioux Falls, SD 57106.
Personal Information (Please print)
Date _____________________
Full Name ____________________________________________ Female Male
Address_______________________________ City ________________State ______ Zip_____________
How long at this address? __________Home Phone _______________ Cell Phone _________________
E-mail Address __________________________________________________________________
How do you prefer to be contacted by us? Home Cell Business E-mail
Employment
Are you employed? Yes No Self-employed
Employer Name: ______________________________________________________________________
Employer Address: _____________________________________________________________________
Your position/ title: ____________________ Business phone: (
) _____-______-______ ext.______
Education
Select the highest degree acquired:
High school/GED Associate’s degree Bachelor’s degree Master’s degree PhD Other
Name of school(s): _____________________________________________________________________
Girl Scout History
Are you already a Girl Scout member? Yes No Registration Attached
How long have you been involved? As a girl member __________As an adult member______________
At which Girl Scout council(s) have you volunteered? ________________________________________
What volunteer role(s)/position(s) have you held? ____________________________________________
_____________________________________________________________________________________
Revised 5/4/11

References (list two)
References are required of the volunteer application process. Membership Assistant will take a reference
over the phone. References may fill out attached forms and return to Girl Scouts.
Name_________________________________________Name_________________________________________
Day Phone______________Evening Phone___________Day Phone____________Evening Phone______________
Address_______________________________________ Address_______________________________________
City_________________ State_________ Zip________City_________________State_________Zip__________
E-mail ________________________________________ E-mail _________________________________________
General Information
Have you worked/volunteered with children? Yes No If yes, in what capacity? __________________
______________________________________________________________________________
What distance are you willing to travel to volunteer? 15 miles 30 miles
More than 30 miles
Special Skills
Describe your specialized skills, talents, and interests: ________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Which languages other than English do you speak and understand proficiently? ____________________
Interests Indicators
Volunteer availability? (Select all that apply.)
Day(s): Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays
Times of day: Mornings Afternoons Evenings
Ideal volunteering duration: (Check all that apply.)
Occasional (e.g., single events) Four to six months
One to twelve weeks
One year
Preferred volunteer service: (Select all opportunities that you are interested in.)
Direct service (working directly with girls)
Which grade levels are you interested in working with?
Grades K–1 Grades 2–3 Grades 4–5
Grades 6–8 Grades 9–10 Grades 11–12
Program opportunities I am interested in? (Check all that apply.)
Camp Events Series Troop Travel
If you checked troop above and know the role(s) you will be serving in, please check:
01 Group/Troop Advisor/Leader
02 Assistant Group/Troop Advisor/Leader
03 Group/Troop Support Volunteer
11 Service Team/Unit Volunteer
Indirect service (not working directly with girls but supporting adults who work directly with girls)
Trip planning Recruiting Community cultivation
Event coordination Product sales Finances
Customer service - store Interviewing Learning facilitation
Volunteer mentoring Communications Clerical work
Other (Please specify): _________________________________________________________
Revised 5/4/11

Background Check Authorization and Consent for Release of Information
I, _____________________________________ __________________________ _______________
Last Name First Name Middle Name
_______________________________________________________________________________________________
Current Address
Dates Lived Here
Addresses for the Past Seven Years: (include street, city, state, zip code)
Dates of Residence:
Date of Birth Other Names Used (including maiden name) Years Used
_____
Social Security Number Driver's License # State
E-mail Address (may be used for official correspondence)
I consent and authorize Girl Scouts—Dakota Horizons to obtain an independent criminal background report and
Social Security number validation report through IntelliCorp Records, Inc., located at 3000 Auburn Drive, Suite
410, Beachwood, Ohio 44122, and also any out-of-state agency if necessary. I further authorize Girl Scouts –
Dakota Horizons to request or receive information which will include but not be limited to motor vehicle reports,
past employment and education records, and/or references from any persons, schools, or previous volunteers only if
pertinent to my potential work as a volunteer. I understand that a credit report may be requested if my assignment
includes handling money.
Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc. and Girl
Scouts—Dakota Horizons for identification purposes and for the release of information which will be considered in
determining suitability for volunteering. I agree to provide additional information if necessary to process my
application.
‣ I understand that the pre-appointment background check requires my full name, date of birth, driver’s
license number and social security number. I understand that the information I have provided may be
verified by contacting persons or organizations listed in the application or by contacting any person or
organization that may have information concerning me.
‣ I certify that entries made by me in this form are true, complete, and accurate to the best of my knowledge,
and are made voluntarily and in good faith. I understand that any false statements or answers by me may
disqualify me for volunteer services or will be sufficient grounds for termination. Moreover, I understand
that failure to complete this form will preclude me from volunteer opportunities with the Girl Scouts –
Dakota Horizons.
‣ I understand and agree that any omission, false statement, misleading statement, or answer made by me on
my application or any supplements to it and in any interviews will be sufficient grounds for rejection or
discharge from appointed position. I further understand that I will receive a complete and accurate
disclosure of the nature and scope of the background verification, in the event such investigation negatively
affects my placement as a volunteer.
I hereby release and agree to indemnify Girl Scouts – Dakota Horizons and IntelliCorp and each of their officers,
directors, employees, and agents harmless from and against any and all liability, expense (including court costs and
attorneys’ fees) and claims for damage of any nature whatsoever.
I authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc. to furnish the abovementioned
information. This authorization will remain valid during the course of my involvement with Girl
Scouts—Dakota Horizons.
________ _______________________________________________ _______________
Printed Name Applicant Signature Date
DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND. LEGAL ADVICE SHOULD BE SOUGHT FROM
YOUR ATTORNEY. WE MAKE NO CLAIMS, PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS, OR ADEQUACY OF
THE INFORMATION CONTAINED HEREIN. WE MAKE NO WARRANTY THAT THIS FORM IS APPROPRIATE FOR YOUR PARTICULAR
NEEDS.
The information on this form is not to be duplicated and is to remain within a secure and confidential environment.
Revised 5/4/11