Volunteer Application
Name Date
Address Home Phone
E-Mail Address Cell Phone
Education
How long have you lived in Colorado?
Current Place of Employment Position
Please list any experience or training you may have had with individuals who have mental illnesses (include places, dates of service, types of experience, ages, diagnoses, including volunteer experience):
Agency Dates Duties and Responsibilities
Professional References
Name Email Phone
1.
In what capacity does this person know you?
2.
In what capacity does this person know you?
3.
In what capacity does this person know you?
Reasons for volunteering (in brief):
Length of time you are able and willing to commit to volunteer at the MHP?
Where did you learn about this volunteer program?
Please note any physical limitations that require accommodation
Days and times you are available to volunteer:
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday
Number of hours per week you are able to volunteer:
Are you bilingual? Yes No If yes, in which languages are you fluent?
Please list any anticipated short or long-term absences longer than two weeks
Do you have a reliable transportation? Yes No
Do you have a valid driver’s license? Yes No
If yes, are you willing to transport clients in a MHP van as part of your work? Yes No If “no’” please explain
If volunteering for class credit, are there specific requirements that MHP needs to know about (include contact person)?
List your two major strengths regarding working with people.
List your two major weaknesses regarding working with people.
List five activities you would like to teach or share.
For which position or program would you like to volunteer?
Youth Advocate Groups Warner House (hospital alternative)
Friendship House (or other residence)
Emergency Psychiatric Services (EPS) - grad students only
Moving to End Sexual Assault (MESA)
Chinook Clubhouse Administration/Fund Raising
Halcyon Boulder Elementary Day Treatment classroom
Older Adult Specialized Services Wellness
No Preference
Other
______
RIGHTS AND RESPONSIBILITIES
I agree (for myself or for my minor child/ward) to volunteer for Mental Health Partners, and understand and agree to the following:
1. I will follow Volunteer Program instructions and regulations to perform my service to the best of my ability.
2. I agree to attend any trainings or Orientations required to fulfill my commitment.
3. I will act within the scope of my volunteer duties as a Mental Health Partners volunteer, valuing and upholding its mission, but not as a Mental Health Partners employee or agent.
4. I will not divulge any confidential information that I learn while participating in the Volunteer Program.
5. I understand Mental Health Partners runs background checks on all volunteers and may ask for further background checks such as fingerprints if my volunteer position involves working with children.
CONVICTION RECORD
Answer this section truthfully, including all offenses of which you were convicted, pleaded no contest and /or placed on probation, fined, or given a suspended or deferred sentence. Do not list arrests. Include any convictions by military trial and any criminal charges for which you are awaiting disposition. List all cases other than minor traffic violations. Driving under the influence, careless, reckless, or hit-and-run driving are not minor traffic violations. If you are in doubt, please list the offences.
PLEASE NOTE: A full disclosure by you is to your advantage as your record does not necessarily disqualify you for volunteering.
Have you ever been convicted of a violation of any ordinance or law other than a minor traffic violation? no yes
If yes, provide the information requested below for each offense.
Offense: Date: Sentence/Fine:
Offense: Date: Sentence/Fine:
Offense: Date: Sentence/Fine:
Signature:
Date:
Please send application to or Volunteer Coordinator 1333 Iris Ave. Boulder, CO 80304