Are You a Registered Member of a Diocesan Parish? Yes No

Volunteer Screening Form

This form is to be completed by all applicants for all volunteer and intern positions. This is not an employment application. Persons seeking employment will be required to provide additional information. This process is used to help CATHOLIC CHARITIES provide a safe and secure environment for children, youth and adults who participate in our programs and use our facilities.

Personal Information

Name / Last: / First: / Middle:
Street Address
Apt #
City / State / Zip Code
Home Phone / Work Phone (If applicable)
Emergency Contact Information
Name
Phone Number
Employer Information
Employer Name
Employer Address

Are you a registered member of a Diocesan Parish? Yes No

If yes, since what date?

Name of Parish ______City ______

List all other churches you have attended or been involved with during the last five years:

Church / Address / Involvement / Dates

List any skills, talents, education, training or experience, including licensure or certification that would be of assistance in your volunteer experience:

______

Do you have a special interest in one of our program areas or offices? If so, which one(s)?

______

Which are you seeking?

A brief volunteer opportunity (one day or one project)

A seasonal opportunity (summer, tax season, etc)

An on-going opportunity (regularly scheduled hours)

What days and times are you typically available?

______

List three personal references you have known three or more years (not family members):

Name / Address / City / State / Zip / Phone 1 / Phone 2

List your City, County, State and dates of residence for the past five years:

City / County / State / Dates

Because CATHOLIC CHARITIES cares for our children, youth and adults and desires to protect them, we ask you to please answer the following questions. We understand the following questions are personal and we will take reasonable precautions to protect your privacy.

Social Security Number / Date of Birth
Driver’ s License # / State issued

Have you ever been convicted of, pleaded guilty or no contest to, placed on probation for, given probation, given community supervision or given deferred adjudication for a crime or are you now under charges for a criminal offense?

YES NO

Answering yes to this question will not automatically exclude you from volunteering. The following lines are for any explanation or details you would like to include.

______

Applicant’s Signature ______Date______

CATHOLIC CHARITIES USE ONLY

Interviewed by: ______Date______

Reference Check by: ______Date______

Reference Check by: ______Date ______

Criminal Background Check by: ______Date______

Clear ______Not Clear ______

8/15

SCL