Volunteer application

VOLUNTEER APPLICATION

To print a "paper application", please "print" this page and an application will print for you to the printer you select.

MAKE NOTE OF YOUR PASSWORD FOR FUTURE USE

Volunteer Location Choice

PERSONAL INFORMATION

* First Name

MI

* Last Name

* Preferred Name

* Home Address

* City

State

* Zip Code

Mobile phone

Home phone

Work phone

* E-mail address

Gender

Are you now, or have you ever been, a Holland Home Employee?

EMERGENCY CONTACT INFORMATION

* Contact name

* Relationship

Address

City

State

Zip Code

Mobile phone

Home phone

Work phone

E-mail address

REFERENCE 1 OF 2 (no relatives - MUST provide email and/or phone)

* Name

Relationship

E-mail

Phone

Organization

Address 1

City

State

Zip/postal

REFERENCE 2 OF 2 (no relatives - MUST provide email and/or phone)

* Name

Relationship

E-mail

Phone

Organization

Address 1

City

State

Zip/postal

Authorization for a Criminal Background Check

An investigation consumer report consisting of a criminal conviction background check will be obtained on all new employees and volunteers of Holland Home. This report will be used for employment and volunteer purposes only. You have the right to make a written request within a reasonable period of time for information concerning the nature and scope of the investigation. In the event you desire this information, please contact the Human Resources Department (employees) or the Volunteer Office (volunteers). This Notice is authorized by the Fair Credit Reporting Act, Section 604(b).

I authorize Holland Home to conduct a criminal background check with the State Police, County Sheriff Departments, and/or a Consumer Reporting Agency for the purpose of determining my suitability for employment/volunteer work with Holland Home. I have listed below all crimes for which I have been convicted, including the date ofsuch convictions, as well as any pending felony charges. I acknowledge that any omission or falsification of this form shall be grounds for discharge if I am employed or assigned as a volunteer.

* Full Legal Name

* Drivers License Number (including State)

Have you ever been convicted or plead guilty or no contest to a crime?

Do you have any felony charges pending against you?

List of Convictions

ADDITIONAL INFORMATION

* How did you hear about us?

Skills you are willing to share

How long can you commit to volunteering:

How frequently can you volunteer:

Highest education

Military Experience

Communication Language

Additional languages

I am a student.

I attend school/college:

I am employed.

I work at (employer):

* Reason for wanting to volunteer or what you hope to do as a volunteer?

Attestation of Application Answers and Information Provided

I hereby represent that the above information is true and complete. I have not withheld anything from this application which, if disclosed, would affect this application unfavorably. I understand that if Holland Home should determine at any time that any of the requested information was withheld by me, or that any of the statements given in this application were false or misleading, I may be refused the opportunity to volunteer, or, if currently volunteering, would be discharged immediately. I understand that I will be free to leave my volunteer position at any time with or without cause; and I understand and agree that Holland Home also may terminate my volunteer duties at any time with or without cause.

If I become a Holland Home volunteer, I will comply with all rules, regulations, policies and communications directed to volunteers. I hereby authorize Holland Home to conduct a routine criminal history check (if I am 18 or older), and thoroughly investigate my work, medical and personal history that is job-related. I also authorize Holland Home to communicate with the references I provided above. If arrested or convicted for any of the following criminal offenses-abuse, neglect, assault, battery, theft, fraud, criminal sexual conduct, or any felony-I agree to immediately report it to the Volunteer Services Department.

I understand that I may not be selected as a volunteer for any reason, and that if I become a volunteer, my status as such may be terminated at any time for any reason.

* I AGREE

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Full Legal Name (e-signature)

* Type Full Legal Name (e-signature)