BLUE RIDGE VOLUNTEER APPLICATION
All applicants must be at least 15 years old and will be required to submit a background check as part of the application process.
Which program would you like to volunteer for?
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Home Delivered Meals
Circles
Childcare
Adult Day Center
Clerical Department
Weatherization Department
Community Service Department
Congregate Nutrition Site
Full Name
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Spouses Name
Address
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Full Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
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Email
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example@example.com
Cell
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Please enter a valid phone number.
Home
Please enter a valid phone number.
Work
Please enter a valid phone number.
Drivers License Number
State Issued
Drivers License Expiration Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Emergency Contact Name
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Emergency Contact Address
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Emergency Contact Phone Number
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Please enter a valid phone number.
Please list your volunteer experience:
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How did you learn about our need for Volunteers?
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What Home Delivered Meals Route area are you interested in?
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Lenoir
Gamewell
Whitnel
Hudson
Granite Falls
Day(s) available for meal route
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Monday
Tuesday
Wednesday
Thursday
Friday
Frequency
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Daily
Weekly
Monthly
Other
What do you already know about the Circles program
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How would you like to be involved with Circles?
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Provide direct mentorship to a Circle Leader (participant)
Speak to our class about a topic that will help them in their self sufficiency journey
Serve on a planning committee
What day(s) would you like to volunteer for BRCA?
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Monday
Tuesday
Wednesday
Thursday
Friday
Frequency
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Daily
Weekly
Monthly
Other
Have you previously volunteered at BRCA?
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Yes
No
If yes, when and what program
Why do you want to volunteer at BRCA?
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To fulfill club or organization hours
For community service requirements
To further knowledge about BRCA and its programs
Personal interest in supporting community organizations
Other
Do you have any family members who are affiliated with Blue Ridge Community Action (BRCA)?
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Yes
No
If yes, please provide the names and relationships of the family members
If you are currently enrolled in school please provide the name of your school and grade you are currently in:
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BRCA VOLUNTEER Confidentiality Agreement
In connection with my activities as a volunteer for Blue Ride Community Action. I agree to hold all information I may have access to about clients or customers or former clients to be confidential and will not divulge any information to unauthorized persons. I understand that the divulging of confidential information to unauthorized persons will make me subject to either civil action for the collection of monetary damages and/or suspension.
Signature
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Date
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Month
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Day
Year
Date
Signature Spouse If Applicable
Date
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Month
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Day
Year
Date
Witness If Required
Date
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Month
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Day
Year
Date
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AUTHORIZATION AND ACKNOWLEDGMENT REGARDING BACKGROUND INVESTIGATION
I acknowledge receipt of the DISCLOSURE -NOTICE REGARDING BACKGROUND INVESTIGATION and "A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT" and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, military branch, institution, school or university (public or private), information service bureau, past or present employer or supervisor, private business, the insurance company or personal reference, and/or other persons to furnish any and all background information requested by BIB, additional third-party organizations acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ("fax") or photographic copy of this Authorization shall be as valid as the original. Personal Identifying Information Needed For Background Check -To facilitate a background check on you, please complete the information below and include all past or current names used (e.g., maiden, surname, alias)
Applicant Signature
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Date
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Month
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Day
Year
Date
Last Name
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First Name
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Middle
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Home Street Address
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ApartmentUnit
City
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State
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Zip
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Date of Birth
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Month
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Day
Year
Date
Social Security Number
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Gender
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Email Address
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example@example.com
Phone
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