Volunteer Application

Thank you for your interest in volunteering with Jobs for Life

Name

Address

City, State, & ZIP

Daytime Phone

Evening Phone

Email

Date of Birth


In case of emergency, please notify:

Name

Relation

Daytime Phone

Evening Phone


Current Employment Information:

Current Employer

How long have you been working there?

Job Duties


Have you ever been convicted of a felony?

If Yes, then please explain:


Are there any felony charges pending against you now?

If Yes, then please explain:


How did you hear about the program?

What experience/skills/education do you bring to the position of program volunteer?

Volunteering Availability: MondayTuesdayWednesdayThursdayFridaySaturday

Hours:

I hereby certify that all statements on this application are made truthfully and without evasion, and further understand and agree that such statements may be investigated. If found to be false, will be sufficient reason for not being placed and may result in dismissal. I authorize all references listed to provide the Mosaic CCDA and/or its agents any and all information concerning my experience, education, and any other pertinent information they may have and release all parties from all liabilities from any damage that may result from furnishing it to you. I hereby waive written notice that employment information is being provided by any person or organization. I hereby authorize the Mosaic CCDA to secure a criminal conviction history from the appropriate law enforcement agency should it be determined necessary to do so.

CONFIDENTIALITY STATEMENTS
Consent to Share Confidential Information: I understand that the volunteer screening proves includes both criminal background checks and references checks. I give permission to have the results of these checks shared with the placement sites considering my involvement as a volunteer.

Confidentiality Agreement: I understand that in providing my services as a volunteer with Mosaic Christian Community Development Association (Mosaic CCDA), I will respect the confidential nature of the knowledge I will gain concerning the academic performance, behavior and personal information of the children with whom I work. If a child tells me something or I notice something that may indicate his/her safety is at risk or he/she is in emotional distress, I will report that information to my supervising teacher. I also agree not to initiate contact with the children with whom I work or their families outside of the school or program setting to which I have been assigned.

The staff of the Mosaic CCDA will treat the information on this application in a confidential manner. However, appropriate information will be reviewed by/with the program director prior to any placement being approved.