Volunteer Application “I’ve seen and met angels wearing the disguise of ordinary people living ordinary lives” – Tracy Chapman Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Gender* Male Female Prefer Not to Answer Emergency Contact PersonEmergency Contact PhoneEmploymentEmployer*Type of Organization / Position*Employer PhoneBusiness Address* Street Address City State / Province / Region ZIP / Postal Code May we contact you at work* Yes No Email Drivers License / State IssuedPrimary Language / Secondary LanguageVolunteer LogisticsI am interested in volunteering as: ( Select all that apply)* Court Appointed Special Advocate/ CASA Mediator Fundrasiers / Special Events I am interested in working in* Either Tioga County Broome County I have my own transportation* Yes No Education HistorySchool*Field of Study*Degree*Date of Completion*School*Field of Study*Degree*Date of Completion*SchoolField of StudyDegreeDate of CompletionExperienceYouth, Legal or Other Experience*List any specfic Qualifications/ Skills/ Interests you have that woud be an asset to this program*Explain any experience you have had involving: Child Welfare, Foster Care, or the Court System*Additional InformationHave you ever been convicted of a crime?* No Yes ExplainCan you commit to a minimum of one year to the ACCORD Program?* Yes No Explain why you wish to participate in this program?*How did you become aware of ACCORD?*Are there any family issues that make you uncomfortable to work with? (Explain)*ReferencesName First Last PhoneAddress Street Address City State / Province / Region RelationshipName First Last PhoneAddress Street Address City State / Province / Region RelationshipAddress Street Address City State / Province / Region Name First Last PhoneRelationshipReleasePlease sign and check the appropriate section* Mediation and General Applicants Certification and Agreement The criteria used in the selection of volunteers have been established to ensure that the individual is able to meet the responsibilities of being a volunteer of ACCORD. No individual will be rejected based on race, color, religious creed, national origin, sex, age or marital status. I hereby certify that the facts set forth in this volunteer application are true and complete to the best of my knowledge. I understand that if accepted as a volunteer, falsified statements on this application shall be considered sufficient grounds for dismissal, and I will be authorizing I understand the information in this application and that otherwise may be obtained will be used only for determining my eligibility for volunteer service and will be kept confidential.Full Name ( Used as Signature)*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920* CASA Certification and Agreement I understand that by signing below, I authorize a National criminal records and a child abuse state central registry check to be made concerning my suitability as a volunteer. Any applicant found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sex offense, child abuse or neglect or related acts that would pose risks to children or the CASA Programs credibility is not accepted as a CASA volunteer. I understand the information in this application and otherwise obtained will be used only for the purpose of determining my eligibility as a volunteer. All information will be held in confidence. Criteria used in the selection of volunteers will be such as to insure that the individual is able to meet the responsibilities of a volunteer Court Appointed Special Advocate. No individual will be rejected based on race, color, religious creed, national origin, sexual orientation, age or marital status. I hereby attest that all information given in this application is true to the best of my knowledge.Full Name ( Used as Signature)*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged.