Name First Name Last Name Date Previous Names DOB Social Security # Why is this required? Volunteers work with our youth and we need to conduct background checks for quality assurance purposes. Address Street Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Email Address Driver's License # ____________________________________________________ Educational Background: College College Class Year College Class Year: Year Year196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034 High School High School Class Year High School Class Year: Year Year196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034 Organizations (e.g. Key Club, Circle K, etc) ____________________________________________________ Employment: Current Employer (if any) Position Supervisor's Name Phone # May we contact your current employer? Yes No If not, why? ____________________________________________________ Background Info: Have you ever been convicted of a crime? Yes No If yes, please explain Have you ever been investigated or the abuse or neglect of an individual? Yes No If yes, please explain ____________________________________________________ Additional Questions: How did you hear about PSL Services/STRIVE? Why are you interested in volunteering? What programs of PSL Services/STRIVE are you interested in volunteering for? Friday Night Social Tweens Wednesday Night Educational series Fundraisers (STRIVE Rocks, Auction etc.) Events/Planning Committees Please contact me about how I can help What are three words that best describe you? Are there any services you could offer to PSL Services/STRIVE? (sewing lessons, yoga, etc.) ____________________________________________________ Personal References: 1. Name Relationship Phone Email 2. Name Relationship Phone Email 3. Name Relationship Phone Email ____________________________________________________ Photo Release: Pictures of volunteer (s)’s activities may be taken and used for publicity purposes including but not limited to publications in commercial periodicals and program newsletters. Pictures of volunteer (s)’s activities may be taken and used for publicity purposes including but not limited to publications in commercial periodicals and program newsletters. initials of volunteer or guardian if under 18 ____________________________________________________ Applicant Agreement: I hereby certify that the facts set forth in and above the volunteer application are true and complete to the best of my knowledge. I hereby authorize you to make any investigation of any personal employment history record including the use of investigative agencies or bureaus of your choice. This report may include information as to your character, general reputation, personal characteristics; criminal and motor vehicle record checks will be performed. I authorize previous employers, schools which I attended, and character references to provide information pertaining to my contact with them. I understand that falsified statements or material omissions on my application shall be considered sufficient cause for dismissal. Signature Date
