Volunteer Services Department

CONFIDENTIAL VOLUNTEER APPLICATION

Date

SECTION 1: Personal Information

Name:

Address:

City, State, ZIP:

Phone: Work: May we contact you at work?  Yes  No

Home:

Cell:

Email:

* Volunteers and/or Interns working directly with our clients must be 21 years of age.

 Male  Female Age: Date of Birth:

Demographic information requested by our funders:

(All volunteers will be considered impartially and without bias of race, religion, sex, age, national origin, physical impairment, or sexual preference).

Marital Status:  Single Married

Race/Ethnicity:

African American

Asian

White

Hispanic

Native American

Pacific Islander

Multi-ethnic

 Other

Primary Language* English Spanish Other:

Secondary Language * English Spanish Other:

SECTION 2: Areas of Interest

 WINGS mentoring

Administration

 Development/ Special Events

Flo’s on 7th Resale Store

Auxiliary

Board of Directors

Girls Leadership Academy

Other:

SECTION 3: Employment and/or Education

Employment Status  Full Time  Part Time  Not Employed  Retired

Name of Employer:

Position and Job Description:

Brief description of additional work experience/history:

Education:

High School Diploma

Some College

Undergraduate Degree

Graduate Degree

Other

Major and Degree:

SECTION 4: Volunteer Experience

List volunteer experiences:

Organization / City/State / Position/Responsibility / Dates of Service

Current community activities, memberships, etc.:

Brief description of experience working with children:

Detailed description of hobbies, interests, skills, and areas of training/expertise:

Please describe your personality:

SECTION 5: Criminal and Health History

Have you ever been arrested or convicted of a crime (including a DUI)?  Yes  No

If yes, please provide dates and explanation:

Have you ever been convicted of child abuse or neglect?  Yes  No

If yes, please provide dates and explanation:

Do you have a valid driver’s license? Yes No

License Number: State: Exp. Date:

Has your driver’s license ever been suspended or revoked?  Yes  No

If yes, please provide dates and explanation:

Have you had a physical exam in the last 2 years ?  Yes  No

(required for all volunteers having direct contact with our students at Girls Ranch only per DES Contract)

Do you currently hold DPS Level 1 Fingerprint Clearance Card?  Yes  No

(required for all volunteers having direct contact with our students)

If yes, please provide the card number and expiration date.

Card # ______Expiration Date ______

Have you had a TB test within the past 12 months?  Yes  No

(required for all volunteers having direct contact with our students)

Are you CPR and First Aid certified?  Yes  No Expiration Date:

(required for mentors and volunteers providing transportation)

SECTION 6: References

List three (3) personal references. If you are employed, one reference should be from your employer. Please do not list relatives or anyone living in the same household with you.

Name:

Phone:

Email:

Relationship:

Name:

Phone:

Email:

Relationship:

Name:

Phone:

Email:

Relationship:

SECTION 7

I, , hereby affirm that all of the answers provided on my application are true. I understand that misrepresentations or omission of facts called for is cause for dismissal. I hereby authorize Florence Crittenton to investigate my background and to contact the above given references for the purposes of determining my suitability as a potential volunteer.

Signature: Date:

Please submit your completed application to:

Volunteer Services Manager

Florence Crittenton

715 W. Mariposa St.

Phoenix, AZ 85013

(602) 274-7318

FAX - 602-274-7549

Revised 1/13/17