Volunteer Application Form

**The information requested is necessary to perform a background check before your application can be considered for volunteer opportunities. Your application WILL NOT BE CONSIDERED unless all fields are completed.**

Name: / DOB: / Social Security #:
Address: / City: / State: / Zip:
Home Phone: / Work Phone: / Email
Where did you learn about our volunteer opportunities?
Are you seeking to volunteer in order to satisfy court-ordered community service?

DEMOGRAPHIC INFORMATION (optional) This information is used for statistical data in applying and/or reporting for grants.

I am: / Male / Female
Ethnicity: / Caucasian / African American / Hispanic
Asian / Hmong / Native American
Other

SKILLS AND EXPERIENCE

What is your educational background/occupation?
In which way are you most comfortable interacting with youth? (Physical Activity/Sports; Mental Activities/Board games; Arts and Crafts/cooking & crafts; Technological activities/Computers)
What are your hobbies?
Do you have any past or present volunteer experience? If yes, please describe.
Why do you want to volunteer at the Boys and Girls Club?

INTEREST INVENTORY

Please check the area(s) that interest you. Check as many or as few as you like! I would enjoy:

Music Leader/Assistant-Which type(s)?
Tutoring-Which subjects? / Sports Coach/Assistant-Which sport(s)?
Arts and Crafts Activity / Instructor/Assistant Helping a Child Use a Computer
Listening to a Child Read / Playing Board Games
Assisting with Fundraising / Leading a Recreational Activity
Acting as a Mentor for Teens / Leading a Discussion Group
Assisting with Office and Clerical Work / Chaperoning a Field Trip
Activities not listed above that I am interested in:

Continued….

PREFERENCES IN VOLUNTEERING

Members of the Boys & Girls Clubs are ages 6 to 18 depending on the site. Which age groups would you most enjoy working with? (check as many as you like)?

6 to 8 years old / 9 to 10 years old / 11 to 12 years old
13 to 15 years old / 16 to 18 years old / No preference / all ages

AVAILABILITY

This section will help determine the best days and times for your volunteer activity. Please mark all days and times you will be available to volunteer. (The Boys & Girls Club is not open on weekends)

MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY
Are there any physical limitations or are you under any course of treatment that might limit your ability to perform certain types of
work?

ADDITIONAL INFORMATION AND RELEASE FOR BACKGROUND CHECK

(Please check the applicable response)

Have you ever been convicted of a criminal offense?

/ /

Yes

/ /

No

Have you ever been convicted of child abuse or neglect? / /

Yes

/ /

No

Has your license ever been suspended or revoked? / /

Yes

/ /

No

Are there any other facts or circumstances involving you or your background that would call into question your being entrusted with the supervision, guidance and care of young people?

/ /

Yes

/ /

No

Please use an additional sheet of paper to explain any “Yes” response)

CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT

I certify that all information submitted in this volunteer application, interview, or other information is true and complete, and that I have not knowingly withheld, nor will I withhold, any information that would effect my application or volunteer employment. I understand the employer is under no obligation to consider or reconsider my application at anytime and that acceptance of this application does not constitute an offer of volunteer employment and that falsification of this application will be grounds for elimination from further consideration, or if employed, for dismissal at anytime.

Signature Date

During the application process and at any time during the tenure of my volunteer employment with the Boys & Girls Club of Portage County, I give permission to the Boys & Girls Club of Portage County to obtain records that would, or may have any bearing on volunteering at the Boys & Girls Club of Portage County. These records may include local, state and criminal record checks as well as any records in which I am a complainant, victim, defendant, or mentioned.

Signature Date

Boys & Girls Club of Portage County • PO Box 171 • Stevens Point, WI 54481 • 715-341-4386