Volunteer Application

“I’ve seen and met angels wearing the disguise of ordinary people living ordinary lives” – Tracy Chapman

Date*
Name*
First Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Gender*
- Male
- Female
- Prefer Not to Answer
Emergency Contact Person
Emergency Contact Phone
Employment
Employer*
Type of Organization / Position*
Employer Phone
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
May we contact you at work*
- Yes
- No
Email
Drivers License / State Issued
Primary Language / Secondary Language
Volunteer Logistics
I 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 History
School*
Field of Study*
Degree*
Date of Completion*
School*
Field of Study*
Degree*
Date of Completion*
School
Field of Study
Degree
Date of Completion
Experience
Youth, 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 Information
Have you ever been convicted of a crime?*
- No
- Yes
Explain
Can 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)*
References
Name
First Last
Phone
Address
Street Address City State / Province / Region
Relationship
Name
First Last
Phone
Address
Street Address City State / Province / Region
Relationship
Address
Street Address City State / Province / Region
Name
First Last
Phone
Relationship
Release
Please sign and check the appropriate section
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.*
- 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*
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.*
- 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*
Name
This field is for validation purposes and should be left unchanged.

Volunteer Application

Employment

Volunteer Logistics

Education History

Experience

Additional Information

References

Release