Volunteer Application | The Parenting Place

Applicant Information

Name*

First

Last

Address*

Street Address City State / Province / Region Postal / Zip Code

Date of Birth*

day

/

month

/

year

Phone*

Email*

Emergency Contact Information

Emergency Contact Name*

First

Last

Emergency Contact Phone*

Emergency Contact Relationship to Applicant*

Health Information

Do you have an EpiPen/severe allergies?*

Yes

No

Please list your allergies*

Are there any other physical limitations or medical conditions we should be aware of before you begin volunteering?*

Yes

No

Please list your physical limitations and/or medical conditions

Desired Start Date*

day

/

month

/

year

Deadline for Volunteer Hours (if applicable)

day

/

month

/

year

Desired number of volunteer hours (total)*

What times are you available for these days?*

Education and Experience

What is the highest level of education you have completed?*

Why are you interested in volunteering at The Parenting Place or how did you hear about us?*

Please list any language(s) spoken

References - This reference should be from a non-family member (teacher/professor, supervisor, employer, former employer, etc.

Reference Name*

First

Last

Reference Email*

Reference Phone*

Relationship to Applicant*

Is this volunteer application for a Pre-Trial Intervention? Note: If this is for Pre-Trial intervention, applicant will be charged $8 for the cost to run their background check.

No - Free If This Application is Not for Pre-Trial Intervention

Yes - $8.00 Fee Will Be Added to Cover the Cost of a Background Check

Statement of Understanding & Confidentiality Agreement

By electronically submitting this volunteer application I agree that all statements on the volunteer application are true and accurate; any misrepresentation or omission of facts may result in termination or disqualification. I agree to give The Parenting Place permission to contact the references listed above and release The Parenting Place from any liability as a result of such contact. I understand that all internship placements are contingent upon successful completion of the mandatory training/orientation and background check.

By electronically submitting this volunteer application as a volunteer/intern of The Parenting Place indicates that I do hereby understand that everything said in the context of employment/volunteering with The Parenting Place is confidential. However, please keep in mind that an exception to confidentiality is when there is a need to REPORT SUSPECTED CHILD ABUSE OR NEGLECT as required by law. As a volunteer, you may have access to private records or medical information. All information from clients should be treated as confidential and shall be discussed with authorized personnel only. Volunteers shall also treat official agency business as confidential and shall not discuss or impart any information regarding agency business with any person who is not an employee of The Parenting Place without approval of the immediate supervisor.

Permission to Conduct Background Check

For the safety of our clients, staff and volunteers, we require that all employees and volunteers complete a criminal background check. By answering the questions below and adding your electronic signature, you agree to submit to a criminal background check and a check of the Central Registry for Child Abuse and Neglect. The result of your background check may affect your ability to serve on our staff.

Your background check and personal information will be kept securely by the Volunteer Coordinator at The Parenting Place. If you have any questions about the usage of your information or the background check process, please email deller@tppupstate.org.

PRE-TRIAL INTERVENTION APPLICANTS WILL BE CHARGED THE $8 IT COSTS RUN THEIR BACKGROUND CHECK.

The following information is needed for these procedures:

Have you ever been convicted of a criminal offense other than a minor traffic violation?*

Yes

No

Please explain in detail and include the offense and date of conviction*

Gender*

Male

Female

Total