Volunteer Form – E-Carrington

Volunteer

Office Hours

By Appointment Only

*Times are subject to change. Please contact our office with your scheduling questions.

GENERAL INFORMATION

Date

Supervisor

Name

Period of Volunteerism

Address

City

State

Zip

Contact Number

Alt Number

Email

Fax Number

Resume provided

Yes No

Attach Resume

DOB

EMERGENCY CONTACT

Contact

Relationship

Address

Phone

REFERENCE INFORMATION

#1

Name

Relationship/Affiliation/Organization

Phone

#2

Name

Relationship/Affiliation/Organization

Phone

#3

Name

Relationship/Affiliation/Organization

Phone

EXPERIENCE INFORMATION

Other

VOLUNTEER INTERESTS

Other

Please describe your volunteer interests in more detail

AVAILABILITY INFORMATION

Monday

From

To

Tuesday

From

To

Wednesday

From

To

Thursday

From

To

Friday

From

To

Saturday

From

To

Sunday

From

To

Are you interested in participating with other volunteers for group projects or activities?

Yes No

OPTIONAL INFORMATION

The following information is optional. Please check the appropriate blocks:

Sex

Male Female

Age

Under 18 18-35 36-55 Over 56

How did you hear about Calvary Counseling Center?

PERSONAL HISTORY

In caring for teen mothers and their offspring’s we believe that it is our responsibility to seek adults who are able to provide and promote healthy, safe and nurturing relationships. Please answer the following questions.

Do you have children of your own?

Yes No

Have you ever been convicted of or plead guilty to a crime?

Yes No

If yes, please explain:

Are you using illegal drugs?

Yes No Occasionally

Have you ever gone through treatment for alcohol or drug abuse?

Yes No

If yes, please explain:

Have you ever been ticketed for reckless driving or driving under the influence?

Yes No

If yes, please explain

Have you ever been arrested, detained, or questioned by police for any other illegal actions of any type. (Be Specific)

Have you been treated for any type of Psychiatric disorder?

Yes No

If yes, please explain

Have you ever been accused, charged or alleged to have committed any act of neglecting, abusing or molesting any child?

Yes No

Is there any circumstance or pattern in your life which would make it inappropriate for you to serve with, minors or young adults and their babies, or that would compromise the integrity of Calvary Counseling Center. If yes, please explain.

Explanation

Do you have any communicable diseases i.e., TB Hepatitis B, HIV/AIDS?

Yes No

If yes please explain specify