Johnson County VASIA Program

VOLUNTEER APPLICATION FORM

Johnson County VASIA Program

As the director of the Johnson County VASIA Program I would like to thank you for making application to be Volunteer Advocate. The Volunteer Advocates will be a major source of the success of this program to help Seniors and Incapacitated Adults who do not have someone to assist in their decision making. It is very important that we get to know each other prior to making the commitment required to assist a senior or an incapacitated adult. Please answer the questions a thoroughly as possible.

PERSONAL INFORMATION

Last Name______FirstName______Middle Name______

Other Names Used______Date of Birth including year______

Address______

Email Address______

Sex M_____F______Homephone______Work Number______

Cell Number______

How Long have you lived at the above address______?

Previous address______

EDUCATION

What is you highest level of schooling (please circle) Elementary, Jr. High, High School, College, Graduate School, Other______)

What degrees have you earned______

Major Area Studied______

Have you had any special training? ______

Certificates Attained______

Are you in school now?______If yes are full-time or part-time?______

If you are in school, what school are attending and what are you studying? ______

Do you have any hobbies or special skills? ______

EMPLOYMENT

Occupation______

Employer Name______

Address______

Telephone______

COURT INFORMATION

Have you ever been arrested or convicted of a crime? Yes______No______If yes give details of each conviction include: Charge, date of arrest location and disposition. A conviction will not necessarily preclude you from consideration unless such conviction(s) relates adversely to the volunteer position sought. Use attachments if necessary______

Have you ever had personal experience with Department of Child Services or Adult Protective Services?

Yes______No______. If you answered yes to either of these agencies, please explain in detail each situation; please give dates, location and disposition below.______

Do you give your consent for the program to perform a criminal background check, a Department of Child Services Check and an Adult Protection Check? Yes______No______. Please note that it is a requirement to be accepted as a Volunteer Advocate to have these background checks successfully completed.

VOLUNTEER PROGRAM INFORMATION

Besides English do you speak another language? Yes______No______If you answered yes please list the languages and your level of proficiency: ______

Have you had experience communicating with a senior or incapacitated adult Yes______No______If yes please explain in detail your experiences?______

Do you work for FSSA? Yes______No______

Do you work for any court in Indiana? Yes______No______

Are you currently a volunteer for any other organization? ______

Do you hold an elected position or political position? If yes please explain______

Have you ever had a paid position working with disabled adults or seniors? Yes_____No______

If yes please explain.______

How did you hear about the program?______

Please give three references of people who know you and your abilities and talents as they would pertain to the program. Please include their name, address, a phone number and an email address if known. Also please include your relationship to the person. Are they friend, pastor, etc.?

1.______

2.______

3.______

Please write a few paragraphs telling why you may want to become a volunteer advocate and what you can bring to the program.______Please feel free to place an attachment if you have run out of writing space.

I, the undersigned, hereby understands that a condition to a volunteer position with the Johnson County VASIA position that a criminal background check be completed, a Child Protection Check through the Department of Child Services be completed and an Adult Protection check be completed. I understand a refusal to give my permission will result in my rejection from the Johnson County VASIA Program.

I further acknowledge that I have completed this application form to the best of my ability and all the information provided is true. I understand falsifying any information on the application or misrepresenting facts during the screening process is grounds for dismissal as a VASIA volunteer. I understand that I must participate in an interview with the VASIA staff. I understand that all information provided will remain confidential unless a crime against a child or vulnerable adult is revealed at which that information will be passed on to the proper agency or police department. If selected to be a volunteer, I understand that I must complete the training provided by the Johnson County VASIA program and understand that I will be required to have additional training each year.

Applicant Printed Name______

Applicant Signature______

Date Signed______

Please send application to : Joe Erickson-Director, Johnson County VASIA Director, 5 E. Jefferson St., 3rd Floor, Franklin, IN 46131.