volunteer form

All individuals that wish to participate in “A PLACE TO BE ME” Programming by Children’s Dispensary must complete this application.  This application will help us determine the best position for you. This is confidential information and will not be shared with anyone outside this organization.

If you wish to fill this form by hand and send it to our office, click here to get the print version.


General Information

Name (required)

Today's Date (required)

Address (required)

City (required)

State (required)

Zipcode (required)

Phone Number (required)

Email (required)

Date Of Birth (required)

Social Security Number (required)

Emergency Contact Name: (required)

Emergency Contact Number: (required)

Emergency Contact Name: (required)

Emergency Contact Number: (required)

How did you hear about our programs? (required)

Have you ever worked with special needs children before? (required)

If yes please list


References

Please list three adults who are not family members, but have knowledge of your ability to work with children.

1st reference contact information

Name (required)

Address (required)

City (required)

State (required)

Zipcode (required)

Phone Number (required)

Email (required)

Years known(required)

Relationship (required)


2nd reference contact information

Name

Address

City

State

Zipcode

Phone Number (required)

Email (required)

Years known

Relationship


3rd reference contact information

Name

Address

City

State

Zipcode

Phone Number (required)

Email (required)

Years known

Relationship


Personal Questions

Have you ever been treated for a psychiatric disorder?

Have you ever been arrested, convicted or pleaded guilty to a crime?

If yes, explain:

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

Have you ever been concerned that you may have an addiction to drugs, alcohol, pornography or any other addiction; or has anyone ever suggested that you may have a problem with the above?

Have you been convicted of possession, use or sale of drugs within the last seven years?

Within the past 30 days have you abused alcohol, legal or non-legal drugs?


DISCLOSURE STATEMENT

I understand that my volunteer position at Children’s Dispensary is contingent upon the organization’s review and approval of a truthfully completed and signed Disclosure Statement and receipt of a report declaring no evidence of criminal history from the State Department of Criminal Justice. I further understand that if I am permitted to volunteer, I may be discharged for any misrepresentation or omission on the application or disclosure statement or the request for criminal history.
Note: your form will not be eligible for submission without agreeing to the statement above

First Name (required)

Last Name (required)

Middle Name

Maiden Name

Address (required)

City (required)

State (required)

Zipcode (required)

Phone Number (required)

Email (required)

Date Of Birth (required)

Social Security Number (required)

Drivers license Number (required)

Place of Birth (required)

Previous Address (If you have moved in the last year)

Address (required)

City (required)

State (required)

Zipcode (required)


I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THIS STATE THAT THE FOREGOING IS TRUE AND CORRECT. I authorize investigation of all statements herein and release Children’s Dispensary from liability in connection with the same.

Note: your form will not be eligible for submission without agreeing to the statement above

Type your name (required)

Today's Date (required)