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Web Site: www.kidsafect.org
Sponsored by Connecticut District Exchange Clubs
VOLUNTEER APPLICATION
NAME: ______
ADDRESS: ______
______
HOME TELEPHONE: ______CELL PHONE: ______
EMAIL ADDRESS: ______
OCCUPATION: ______
EMPLOYER: ______PHONE: ______
EDUCATION: (Check highest completed) HIGH SCHOOL: 1 2 3 4
COLLEGE: 1 2 3 4 MAJOR: ______
GRADUATE SCHOOL: DEGREE & MAJOR: ______
Do you have a valid driver’s license? Yes No
Do you have access to a car? Yes No
Do you have liability insurance? Yes No
Do you have any limitations that would prohibit you from performing the duties of a Parent Educator or any other position for which you are applying? Yes No
If yes, please explain: ______
______
Have you ever been convicted of a crime? Yes No
If yes, please explain: ______
______
______
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Have you ever been reported to or involved with the Department of Children and Families?
Yes No
If yes, please explain: ______
______
______
How many hours are you interested in volunteering? ______Week Month
In what area(s) would you like to volunteer? (please check all that apply)
Babysitting for parenting groups or special events
Mentoring during children activity groups
Office work
Family Enrichment Service Program (weekly home-based parenting program)
Special events
Please describe any experience you have had working with children and/or families:
______
______
______
______
______
______
How did you learn about our program? ______
______
I certify that the information I have given on this application is true and complete, and understand that any false information may be cause for discharge.
I further understand and agree to abide by the regulations of this program which specify that for the protection of all, I am prohibited from disclosing the contents of any communications, records, or files. I agree to keep any and all information (identities, addresses, dates, case histories, etc.) completely confidential.
SIGNATURE: ______DATE: ______
On the attached sheet please write a one page autobiography.
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AUTOBIOGRAPHY
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Web Site: www.kidsafect.org
Sponsored by Connecticut District Exchange Clubs
RELEASE OF INFORMATION
FIRST NAME:FULL MIDDLE AND MAIDEN NAME:
LAST NAME:
PRESENT ADDRESS:
PREVIOUS ADDRESS:
DATE OF BIRTH:
PLACE OF BIRTH:
SOCIAL SECURITY NUMBER:
RACE:
SEX:
I do hereby authorize the Department of Children and Families and the Police Department to release any information in their files under the above name and description. This information will be used to assist KIDSAFE CT (Exchange Club Center for the Prevention of Child Abuse of CT, Inc.) in determining my eligibility to serve in their programs.
I hereby release the staff, KIDSAFE CT (Exchange Club Center for the Prevention of Child Abuse of CT, Inc.) and others from any liability or damage which may result from furnishing the information requested above.
SIGNATURE:
DATE:
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Web Site: www.kidsafect.org
Sponsored by Connecticut District Exchange Clubs
REFERENCES
NAME:IDENTIFY 3 REFERENCES: 1 PERSONAL AND 2 PROFESSIONAL (i.e. work or volunteer related). OUR REFERENCE CHECKS ARE DONE MOSTLY BY MAIL. PLEASE PROVIDE COMPLETE ADDRESSES.
NAME:
ADDRESS:
PHONE:
RELATIONSHIP:
NAME:
ADDRESS:
PHONE:
RELATIONSHIP:
NAME:
ADDRESS:
PHONE:
RELATIONSHIP:
I understand it will be necessary for KIDSAFE CT (Exchange Club Center for the Prevention of Child Abuse of CT, Inc.) to check my character references. I hereby give my consent for this information exchange and authorize such persons to release any information requested by KIDSAFE CT (Exchange Club Center for the Prevention of Child Abuse of CT, Inc.).
SIGNATURE: ______DATE: ______
IN ADDITION TO FILLING OUT THE ATTACHED DOCUMENTS, WE NEED THE FOLLOWING INFORMATION FOR YOUR PERSONNEL FILE:
Photocopy of Auto Insurance Card
Photocopy of Driver’s License
Photocopy of Social Security Card
Photocopy of College Diploma
Web Site: www.kidsafect.org
Sponsored by: Department of Children and Families, Connecticut District Exchange Clubs