514 Revolution Volunteer Application
Name
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
AGE
*
GENDER
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Social Security Number:
*
Driver's License Number:
*
Driver's License State:
*
Volunteer Experience:
ORGANIZATION NAME:
First Name
Last Name
ORGANIZATION ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Supervisor Name
First Name
Last Name
Supervisor Phone #:
Please enter a valid phone number.
Additional Information:
What are your reasons for wanting to volunteer for Five14 Revolution?
Religious Affiliations:
Christian
Catholic
Other
If applicable, please provide the following information about your local church:
Church Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you rate your knowledge of the signs to look for concerning victims of human trafficking?
Excellent
Good
Fair
Poor
How would you rate your knowledge of current laws surrounding human trafficking?
Excellent
Good
Fair
Poor
How would you rate your comfort working with survivors who have been mentally, physically, and emotionally abused?
Excellent
Good
Fair
Poor
Have you ever been convicted of a crime?
*
YES
NO
If yes, please explain
Have you been convicted of the possession, use, or sale of drugs within the last 10 years?
*
YES
NO
If yes, please explain:
Have you ever been charged with/ convicted of a sexually based offense?
YES
NO
If yes, please explain:
Has your driver's license been suspended or revoked within the last 12 months?
Yes
No
If yes, please explain:
Emergency Contact Information:
Name
*
First Name
Last Name
Relationship:
*
Length of time known:
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Medical Considerations/ Medications we should know about in case of emergency:
Please list any known allergies:
Your Availability and Position of Interest:
*Paid positions are available for the Restoration House Weekend Staff program. Volunteer Positions are available for both the Outreach Center and Restoration House. Please indicate your interest below:
I am interested in serving in the:
*
Outreach Center
Restoration House
Both
Outreach Center Volunteer: Please list your availability (select all that apply):
Monday
Tuesday
Wesdnesday
Thursday
Friday
Time Slot:
AM (9-12)
PM (12-3)
Restoration House Paid Weekend Staff/ Volunteer: Please list your availability (Select all that apply) *Note paid weekend staff hours are Friday at 5pm to Sunday at 5 pm.
Saturday
Sunday
Time Slot:
AM (9-12)
PM (12-3)
Select the areas in which you would like to serve from the following options. Please check all that apply:
Transportation (i.e.: taking then to your church on Sundays)
Group Lunch (Wednesday)
Financial Planning (Budgeting Help)
Resumé Building
Bible Study
Life Skills Classes (Art,Yoga, Exercise, Job Training, Etc...)
Arts/Crafts Restoration House or Outreach Center
Restoration House Meals
Hotel Outreach
Five14 Storehouse (organization/ inventory)
GED tutoring
Other
Applicants Certification and Agreement
I certify that the facts set forth in this volunteer application are true and complete to the best of my knowledge, and I authorize Five14 Revolution to verify their accuracy to obtain reference information concerning my character and capabilities. I release Five14 Revolution and any person or entity providing such reference information or relating to any decisions made based upon such information. *I give permission to Five 14 Revolution to conduct a criminal background check to the extent that my volunteer duties may involve direct interaction with minors.* If I become a volunteer at Five14 Revolution, I agree to fully adhere to its policies and rules, including those rules relating to maintaining client confidentiality. I recognize as a volunteer, I will serve in a different role that the employees of Five14 Revolution and I am not seeking, nor expecting to receive any compensation of other benefits in return for any services in which I may provide for this ministry (exception for paid weekend staff). I further certify that I have read and that I am in full agreement with Five14 Revolution's Mission Statement and Vision.
*I give permission to Five 14 Revolution to conduct a criminal background check to the extent that my volunteer duties may involve direct interaction with minors.*
Date:
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Month
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