Adult Volunteer Application

FOR OFFICE USE ONLY:
Adult Volunteer Application
Communities In Schools of Georgia in Marietta/Cobb County, Inc.

3104 Creekside Village Drive, Suite 507J, Kennesaw, Georgia, 30144

Phone: 678-503-0901 Email: nrutledge@cisgeorgia.org
First Name
Initial
Last Name
Address
Apt.
City
State
Zip Code
Home Phone
Business Phone
E-Mail
example@example.com
Fax
Date of Birth

Month Day Year
Date
Misdemeanor/Felony Conviction: Y N Please Explain
Gender: M F Ethnicity (Optional)
Employer
Occupation
Education & Degree
Languages (Speaking/Reading/Writing)
Talents/Skills/Interest
Contact In Case of Emergency
Relationship
Phone
Physical Accommodations Needed:
Morning (9-12)

Mentoring Tutoring GA Literacy Program CIS-MCC Office In what capacity would you like to volunteer? When are you available? Give Days and Hours. Afternoon (1-6)
Morning (9-12)
Afternoon (1-6)
What school location are you interested in volunteering?
REFERENCES (please provide two): Full mailing address need
Name
Address

Address

Street Address Line 2

City/State/Zip
Phone
Email
example@example.com
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein the references listed to give any and all pertinent information concerning my employment, personal issues, or other matters, and release all parties from all liability for damage that may result from furnishing same to you.
Signed
Date

Month Day Year
Date
STATEMENT OF RESPONSIBILITY
As a volunteer at Communities In Schools of Georgia in Marietta Cobb County, Inc., I pledge to hold in strict confidence, all personal and official matters which come to my attention.

It is my responsibility to respect and preserve the privacy of the children as well as any detail involved.
Volunteer’s Signature Date

Clear
Volunteer’s Signature Date

Month Day Year
Date
STATEMENT OF UNDERSTANDING
In case of accident or injury, I specifically release Communities In Schools of Georgia in Marietta Cobb County, Inc. and all others from any liability or other obligation.
Volunteer’s Signature Date

Clear
Volunteer’s Signature Date

Month Day Year
Date
CONSENT TO PHOTOGRAPH/QUOTE
I grant permission to use my name/image, in photographs or quotations to be published in print newsletter, brochures, newspapers etc, used in videos, shown on television, or on the Internet, in conjunction with media coverage of events taking place involving Communities In Schools of Georgia in Marietta Cobb County, Inc. or public relations work done for Communities In Schools of Georgia in Marietta Cobb County, Inc.
Volunteer’s Signature
Background Investigation Release Form
I
hereby authorize The Phillips Agency, Inc and/or its agents to conduct an investigation of my Criminal Record including any records maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application. I also authorize The Phillips Agency to obtain information regarding my Employment History, Education History, Driving History and Credit History. I release The Phillips Agency, Inc and/or its agencies and any person or entity which provides information to The Phillips Agency, Inc from any and all liabilities, claims or lawsuits in regard to the information obtained from any and all of the above referenced sources. I also understand and will expect that The Phillips Agency, Inc may contact me before conducting the investigation to obtain other relevant information and to confirm my consent to this investigation. A photocopy of this authorization shall be deemed an original and shall be accepted as such by every person.
Signature

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date
Please print the following information clearly
Name

First Name Middle Name Last Name
Please list any names you have been known by, employed or obtained credit as below
Personal Information
Date of Birth

Month Day Year
Date
Social Security Number
Drivers License Number
Drivers License State
Sex Race
Sex Race
Present Address
Street Address
City
State
Zip
Former Address
Street Address
City
State
Zip
Should be Empty:

FOR OFFICE USE ONLY:

Adult Volunteer Application

STATEMENT OF RESPONSIBILITY

STATEMENT OF UNDERSTANDING

CONSENT TO PHOTOGRAPH/QUOTE

Volunteer’s Signature

Background Investigation Release Form

Personal Information

Present Address

Former Address