VOLUNTEER APPLICATION
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Would you like to be added to our mailing list?
*
Yes
No
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
Rows
Emergency Contact
Name
Relationship
Phone Number
Full Time or Part Time Resident?
*
Full Time
Part Time
If you are a part time resident please indicate the months you are available.
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide two references we may contact (other than relatives)
*
Rows
Reference #1
Reference #2
Name
Phone
Relationship
Are you a past client of Lighthouse Education Center? (This will NOT affect volunteer eligibility)
Yes
No
Are you visually impaired? (This will NOT affect volunteer eligibility)
Yes
No
Have you ever worked with the blind or visually impaired?
Yes
No
Do you have previous volunteer experience? (not a requirement)
Rows
Organization #1
Organization #2
Dates
Duties
Are you willing to take a drug screen and have a background check if it’s required for your volunteer/intern position?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Your current employment status.
Please Select
Full Time
Part-Time
Retired
Student
Other
Highest Education Level & Degree
Rows
Education Level
Degree
Special skills, training, hobbies:
Do you speak any other languages besides English? If so, what?
List any Group or Club Affiliations you are a part of.
Do you have any allergies that we should be aware of?
Please let us know your preferred days of volunteer/intern time. (Check the boxes that best fit)
Rows
AM
PM
Not available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
If your schedule varies, would you like to be on call as needed?
Yes
No
(Optional) How can we best work with your schedule?
Are you willing to travel to any counties we serve? (Check all that apply)
Sarasota
Manatee
Highlands
DeSoto
Charlotte
Do you prefer to work with teens or adults? (check all that apply)
Teens
Adults
How do you prefer to work? (check all that apply)
Alone
One on One
Small Groups
Please check all boxes of volunteer opportunities that interest you:
Administrative support
Field trips
Teen summer program
Arts & crafts
Driver for a person with a visual impairment
Special events - such as fundraisers or event planning
Marketing/outreach
Web design/development
Presentations and public speaking
Health fairs
Photography or Videography
Low vision store assistance
Assistive technology assistance
Peer facilitator for a support group or class
Music, performing arts, dancing or cooking for client groups
Visual translator/reading for clients
Construction/maintenance service such as: painting, carpentry, plumbing, landscaping
Other
How did you hear about us?
Why are you interested in volunteering with Lighthouse Education Center?
Is there anything additional you would like us to know about you?
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Acknowledgement & Authorization
In consideration for being accepted as a volunteer by Lighthouse Vision Loss Education Center, I understand and agree to the following.
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My interview will be followed by a mandatory orientation about Lighthouse Education Center and working with the blind and visually impaired before any placement is offered.
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Completing this application, having an interview and attending a volunteer orientation does not guarantee a volunteer placement will be offered to me.
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In the course of volunteering, I may have access to confidential information about Lighthouse Education Center and its clients, donors, employees and/or volunteers. The organization operates in accordance with applicable professional, ethical and legal principles established by recognized bodies including HIPPA and FERPA requirements. I agree to keep such information in the strictest confidence, and I understand that these federal and state law (s) could be violated if I share this information. If in doubt, I will ask my supervisor about whether certain information is to be considered confidential. I will not remove any confidential information of any kind from the premises.
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In the course of volunteering, I may have access to confidential information about Lighthouse Education Center and its clients, donors, employees and/or volunteers. The organization operates in accordance with applicable professional, ethical and legal principles established by recognized bodies including HIPPA and FERPA requirements. I agree to keep such information in the strictest confidence, and I understand that these federal and state law (s) could be violated if I share this information. If in doubt, I will ask my supervisor about whether certain information is to be considered confidential. I will not remove any confidential information of any kind from the premises.
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I hereby affirm that the information provided here and in my interview is true and complete to the best of my knowledge, and I authorize Lighthouse Education Center to investigate and/or independently confirm any information it deems necessary. I understand that false or misleading information or material omissions in my application or interview, or discovered during a background check if performed, may disqualify me from being placed as a volunteer or, if I have already been placed as a volunteer, could result in my immediate discharge.
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I acknowledge that no employment contract has been or will be created by my volunteer relationship with Lighthouse Education Center. I am a volunteer and I may resign at any time. Lighthouse may change or terminate my volunteer position at any time without notice, and may discontinue its relationship with me at any time for any reason. My service is strictly voluntary and I will not be paid or receive any compensation for my time and/or services.
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I realize that by accepting a Lighthouse Education Center volunteer placement, I am making a commitment. I have considered the commitment of time and responsibility I can make to this position. If I will be volunteering for time-specific assigned shifts, I will report for them on a punctual and consistent basis, will notify my supervisor of any absences with as much lead time as possible, and will notify my supervisor if I wish to terminate this commitment.
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I understand that safety is a particular consideration at Lighthouse Education Center’s property to serve visually impaired individuals. I will ensure I don’t obstruct passageways and exits, will abide by all written and spoken safety rules and will immediately report any injuries to my supervisor.
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If I will be driving in my capacity as a Lighthouse Education Center volunteer, I will not do so unless I have been approved to do so, will obey all traffic laws and speed limits, and will wear my seat belt and require any passengers to wear their seat belts at all times.
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I realize that Lighthouse Education Center works with teens, aged adults and the disabled, and these individuals can be vulnerable to abuse, neglect and exploitation by their caregivers. In the event that I have reasonable suspicion or knowledge of such behavior toward an individual served by Lighthouse Education Center, I will advise the CEO AND call the Florida Abuse Hotline at 1-800-962-2873.
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Lighthouse Education Center is an equal opportunity organization that evaluates all individuals on the basis of their skills and abilities, and applies similar guidelines to its volunteer program. I understand that Lighthouse Education Center will not tolerate harassment of any kind for any reason either BY or TOWARD a volunteer. Harassment is verbal or physical conduct that creates an intimidating, hostile or offensive work environment. If I have questions about what constitutes harassment, I will contact the Volunteer Coordinator or CEO.
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I understand that no alcohol, controlled substances (illegal drugs) or smoking are allowed on the property, and I will not report to the Lighthouse Education Center to volunteer if I am under the influence.
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I assume the risk and responsibility for any and all claims, legal actions and cause resulting from injury to myself or others, as well as property damage caused by my negligence or my intentional acts. I release Lighthouse Education Center and its representatives from any and all liability arising out of any damage, loss or injury to me or my property incurred as the result of my volunteer activities. My estate shall hold harmless Lighthouse Education Center and its representatives from any claims or actions by my relatives or legal representatives based on my death or injury as a result of my volunteer activities.
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Lighthouse Education Center is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against discrimination in employment, recruitment, advertisements for employment, compensation, termination, upgrading, promotions, and other conditions of employment against any employee or job applicant on the bases of race, color, gender, national origin, age, religion, creed, disability, veteran's status, sexual orientation, gender identity or gender expression.
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I will not make any political or personal statements to the public on behalf of Lighthouse Education Center. In particular, I will not make any statements or release any information about Lighthouse Education Center to any news media except as expressly authorized by Lighthouse Education Center officials.
Lighthouse Education Center’s staff, volunteers, clients and/or others attending our programs may take photographs, videos or recordings of the clients, guests, volunteers and staff for publications and/or broadcast in various media. My personal preference is indicated below:
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I hereby consent and authorize my picture and/or video to be taken and used for any publicity and/or outreach materials to include video, print, Internet, website, radio, television, brochures, magazines, newspaper and any other media. I further consent for my name to be used in connection with the pictures and/or videos. I hereby indemnify and hold harmless Lighthouse Education Center, its staff, Board of Directors, service providers, agents and affiliates, against any and all claims or damages arising out of taking or the use of my pictures, videos and/or name. Any rents, royalties and materials are the sole property of Lighthouse Education Center and may be edited or altered, with no compensation provided.
I do not consent and authorize for my picture to be taken and used for any purposes.
I hereby acknowledge that I have read, understand and agree to all of the statements above.
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Digital Signature (Please type your full name to sign)
For applicants under 18 years of age
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Signature
*
Parent/Guardian Digital Signature (Please type your full name to sign)
Submit
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