Volunteer_Application

Lancaster County Corrections Volunteer Application

Last Name*

First Name*

Middle

Please list any other names you have used

Home Address:

Street*

City and State*

Zip code*

Phone Numbers

Home Phone #

Please enter a valid phone number.

Cell #*

Please enter a valid phone number.

Work #

Please enter a valid phone number.

Email Address*

example@example.com

Date of Birth (Month/Day/Year)*

Date

Height*

Weight (lbs)*

Hair Color*

Eye Color*

Race*

Sex*

MF

Social Security*

Drivers License #*

Employer Name

Employer Location

Occupation/Title

Have you or any relatives or friends been lodged in Lancaster County Corrections in the last 6 months?*

YesNo

If yes, please list the name of the person incarcerated and their relationship to

Do you have any communicable diseases?*

YesNo

Are you currently receiving treatment for mental health problems?*

YesNo

Are you currently receiving treatment by a physician?*

YesNo

Have you ever been convicted for any violation of the law other than minor traffic violations?*

YesNo

If yes please explain

Area in which volunteer services will be performed:*

If 'Other' please explain

Clean / Sobriety Date*

Date

Professional Credentials Held

Past Volunteer Experience

Most suitable days you could provide volunteer services:*

Most suitable times you could provide volunteer services:*

MorningAfternoonEvening

List the names of three persons (other than relatives) who have knowledge of your skills and character:

Ref Name 1

Ref Address 1

Ref Phone 1

Please enter a valid phone number.

Ref Name 2

Ref Address 2

Ref Phone 2

Please enter a valid phone number.

Ref Name 3

Ref Address 3

Ref Phone 3

Please enter a valid phone number.

I agree to comply with the following:

1) I will complete an orientation program with the Lancaster County Department of Corrections ifrequired.

2) My volunteer service will not be monetarily compensated.

3) I will abide by the professional ethics governing the confidentiality of case histories of detainees.

4) I will not knowingly violate Lancaster County Department of Corrections Policies and Procedures whilein the facility.

5) I will not bring contraband into the facility.

6) I will submit to a search of my clothing, purse, packages, person etc. if requested by Corrections staff,upon entering or while at the facility.

7) I will report any problems or irregularities encountered while at the facility to the Programs Director.

8) I give Lancaster County Department of Corrections permission to conduct a criminal historyinvestigation on myself and contact character references I have listed.

9) I will maintain a professional distance from inmates.

10) I will immediately notify the Programs Director if I , any family member or close friend becomeincarcerated with the Lancaster County Department of Corrections.

Signature*

Signature Date*

Date

Please verify that you are human*