Volunteer Application

Personal Data

Name ___Mr. ___Ms. ______Date ______

Address ______

City ______State ______Zip Code ______

Phone number (home) ______(cell) ______(work) ______

Email ______

Work/Education Experience

Please indicate which categories apply to you:

___HighSchool Student___College StudentLast school attended______

___Retired___Parent

___Working adult, occupation ______

___Other ______

Emergency Contact(s)

Name ___Mr. ___Ms. ______Relationship ______

Phone number (home) ______(cell) ______(work) ______

Name ___Mr. ___Ms. ______Relationship ______

Phone number (home) ______(cell) ______(work) ______

Background

Have you ever been convicted of a felony?

___ Yes, please list ______No

Have you ever been convicted of a misdemeanor, not including minor traffic violations?

___ Yes, please list ______No

Volunteer Interests and Availability

How did you learn of LADD volunteer opportunities?

______

______

______

What type of volunteer service interests you?

______

______

______

What time commitment would you prefer?

___One time visit/Special project, stop here and proceed to Terms and Conditions section.

___Community services project requiring _____ number of hours.

___Regular scheduled visit, consent for obtaining background checks required.

___Other ______

Please write in your hours of availability

Hours Available / Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Morning
Afternoon
Evening

Specific program you would prefer to volunteer? ___ Yes, please indicate below___No

______

Previous training, experience, skills or volunteerism you bring to LADD?

______

______

______

References

Name ___Mr. ___Ms. ______Date ______

Address ______

City ______State ______Zip Code ______

Phone number (home) ______(cell) ______(work) ______

Name ___Mr. ___Ms. ______Date ______

Address ______

City ______State ______Zip Code ______

Phone number (home) ______(cell) ______(work) ______

Terms and Conditions

I agree to the following terms and condition:

  • I believe in LADD’s mission to facilitate the education of adults with disabilities to reach their aspirations.
  • LADD has my permission to contact my references and obtain background checks
  • I agree to complete all required trainings necessary to learn about LADD and my position
  • I will notify my immediate supervisor of my volunteer hours each time I volunteer
  • I agree to abide by the principles outlined in the Confidentiality Policy and to ensure and safeguard the confidentiality and privacy of all individuals served and their families, employees, volunteers and the organization from unauthorized disclosure without consent
  • I understand my volunteer opportunity can be terminated by myself or LADD at any time
  • I will follow the dress code
  • I give permission to LADD to use my name, voice and/or image and my verbal or written quote in all LADD media. LADD media may include, but is not limited to, television/radio stories, publications (i.e., Ledger, brochure), newspaper stories, website ( posters, presentations (i.e., video, power point)
  • I hereby release and hold harmless LADD, Inc., their funders, supporters, officers, agents, individuals receiving services and/or employees from any liability for loss or injury to my person or property which might occur due to negligence or other acts or omissions. This release implies to any losses or injuries which may occur as a result of, or during my participation in, volunteer services
  • I agree to abide by the LADD Code of Ethics and honor the principles outlined within. The Code of Ethics will be used as my guide to assist me with staying on course to provide ethical treatment to all in my daily interactions and conduct as a LADD employee
  • I agree to observe safe work practices, so as to minimize the risk of workplace injury to individuals receiving services, others and myself. As a volunteer of LADD, I shall report any observed failure of services being provided through the appropriate channels and complaint process and participate in risk reduction activities where mistakes and adverse events are identified, reported without blame, discussed, and corrected.I will follow emergency response procedures

With my signature below, I certify that all of the information provide on this application is true and complete and I understand that falsification or significant omissions of any information may be considered justification for non-acceptance or dismissal from my volunteer position if discovered at a later date. I understand that I am working at all times on a voluntary basis without compensation and not as a paid employee.

Signature ______Date ______

If volunteering with therapy animals, you must provide proof of immunizations for the animal as well as proof of liability.

Administrative Use Only

Immediate Supervisor: ______

Proof of completion to be maintained in volunteer file / Date
Scheduled/Requested / Date of Completion
Drivers License/Proof of Identification Copy
ODODD Abuser Registry Check
ODH Nurse Aid Registry Check
CourtClerk.com Check
Open Check
BCII Check (FBI check if not resident of OH for previous 5 years)
BMV Driver’s Abstract

Name of Reference: ______Date Checked: ______

Comments: ______

______

______

______

Name of Reference: ______Date Checked: ______

Comments: ______

______

______

______

Effective 11/18/08; 1/20/11