VACY - Programs

Required Entry = *

*Date:

Title:

Name:

*Last Name	*First Name	M.I.	Maiden Name

Have you been known by any other names? (Include previous married names)

Nicknames or how you wished to be called or addressed?

*D.O.B.		*Sex		*Race		*SSN

*Address:

*City, St., Zip:

Telephone:

*Home Phone:		Cell Phone:

*Email
Address:

*Education:

(Highest Level Completed)

List Areas of Study or Degrees Earned

*Currently Employed: If Yes, Employer:

*May you be contacted at work? If Yes, Business Phone:

*Do you have any personal/employment constraints that may restrict your time?

If Yes, Explain:

*Emergency:

*Contact Name		*Relationship		*Telephone

*Drivers
License:

If Yes, What State: License No.: Expiration:

*Have you ever been arrested?
(This does not necessarily exclude you from consideration as a volunteer)

If Yes, Explain:

Describe any volunteer work you have done?

Do you have any special abilities, skills, talents, or hobbies?

Do you prefer to work with any particular age group?

How did you hear about our program?

PROGRAM INTEREST

Which of the following Volunteer programs listed below interest you?

Children First

Community Service

Court Appointed Special Advocates (CASA)

Juvenile Conference Committee (JCC)

Life Skills

Incentives for Change

Facilitating groups for children or adults

VOLUNTEER CONFIDENTIALITY

I fully understand that any information regarding the cases handled by the Juvenile and Domestic Relations Court is strictly confidential. I further understand that it is my responsibility to hold all such information in the strictest confidence. I realize that any breach of confidence is grounds for my being restricted from further participation in the volunteer program and possible prosecution by the client being served.

VOLUNTEER PLEDGE

AS A VOLUNTEER I PLEDGE TO:

Keep all matters confidential and to respect other's privacy.

Be of help to children and to their families.

Maintain a positive, objective and accepting attitude in my association with all people.

Have a deep sense of commitment to the rights of youth, to their growth as individual, and to their development as members of the community.

*Signature: Date:

REFERENCES

Please list three personal references NOT related to you.

Name:
Address:
City, State, Zip:
Telephone:	Home: Work:
Relationship:

Name:
Address:
City, State, Zip:
Telephone:	Home: Work:
Relationship:

Name:
Address:
City, State, Zip:
Telephone:	Home: Work:
Relationship:

The information supplied by me in this application is true to the best of my knowledge.

*Signature: Date:

Please click the "Submit Volunteer Application" button above
to send to VACY and allow you to print a copy.