Volunteer Application
Thank you for your interest in making a difference in the lives of others
Date
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Month
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Day
Year
Date
Full Legal Name
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First Name
Last Name
Preferred Name (optional)
First Name
Personal Pronoun
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Secondary Phone Number (optional)
E-mail
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Occupation/Job Title
If retired, fill this section with 'Retired' and write former employer below
Current Employer
Does your employer offer (check all that apply):
Volunteer time-off program
Donation-matching program
None of the above
Faith-based community (optional):
Name and city
Race - check all that apply (optional):
African-American/Black
American Indian/Alaska Native
Asian
Hawaiian/Pacific Islander
White
Other
Emergency Contact:
Full Name
Relationship
Phone
Experience - volunteer, paid or internship
Most recent experience
Organization
Activity/Job title
Dates
Additional experience
Organization
Activity/Job title
Dates
If desired, submit resume here:
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Skills, hobbies or interests that might be helpful in your volunteer work:
Fundraising
Public speaking
Photography
Marketing
Other
Other
Skills, hobbies or interests
List any languages other than English in which you are fluent:
How did you hear about us?
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Please Select
College/University
Faith-Based Group
Social Media
Current volunteer
Print material
Radio ad
Television commercial
Other support organization
Other (please specify)
Other:
Do you need any special accommodations to perform your volunteer duties?
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Yes
No
If yes, please explain
Are you applying to volunteer in order to complete required service hours?
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Yes
No
If yes, please indicate:
Reason for service hours
Number of hours required
Date hours are due
Volunteer positions of interest (check all that apply):
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Driver (transport clients to and/or from appointments or errands)
Grocery helper (deliver groceries and unload into kitchen) *(specify location below)
Handyperson (e.g. painting, minor home repair, changing light bulbs and batteries)
Homemaker (e.g. light organization, cleaning)
Client Connector (take client grocery orders over the phone and place them online)
Shopper (pick + pack grocery orders on weekday mornings) *(specify location below)
Phone a Friend (ongoing telephone reassurance for one or more isolated clients)
Office Assistant (e.g. data-entry, phoning projects, occasional mailings)
For Shopper and Grocery Helper, which location(s) would you prefer to volunteer at:
Bloomington
Saint Anthony
If you selected Bloomington, which day(s) works best for your availability:
Monday
Friday
Thursday
If you selected Saint Anthony, which day(s) works best for your availability:
Tuesday
Thursday
Wednesday
Friday
Certification/Release:
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for volunteering as may be necessary in arriving at a decision and hereby release any said persons, schools, former employers, and law enforcement authorities from any liability for issuing this information. I understand that this application is not and is not intended to be a contract of employment. In the event of placement as a volunteer, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Help At Your Door. *By applying for a Help At Your Door volunteer role I am giving Help At Your Door permission to run a mandatory background check at this time and every three years for the duration of my volunteer position.
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Parent/Guardian Signature (if under age 18)
* Help At Your Door will cover the cost of completing the criminal background check, but volunteers have the option to pay for the check if they would like to help defray this cost for the organization. The background check is $20. Would you like to cover the cost of your background check? Please indicate:
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Yes
No
Confidentiality/Publication Agreement
Mission: As a Help At Your Door volunteer, I understand I am expected to: •Be aware of the general mission of the agency; providing support to keep seniors and disabled individuals living independently at home. •Project a positive attitude and be reliable and dependable in my volunteer assignment. •Respect all clients, staff and other volunteers. •Conduct myself with honesty and integrity while working with Help At Your Door. •Adhere to staff directions, guidance and policies Confidentiality: I understand that it is my responsibility to protect any information I may learn or be given about the clients of Help At Your Door. It is essential not only to protect client names from public disclosure but to keep all client information confidential. I understand however, that client information will need to be shared with Help At Your Door staff and other volunteers in the course of executing my duties as a volunteer. I also understand that when acting in my capacity as a volunteer for Help At Your Door or identified as a Help At Your Door volunteer, I must refrain from giving my personal opinions to the media, press, public audiences, television and/or radio, as they may be interpreted as representing the official position of Help At Your Door. Liability: I understand and fully acknowledge that in volunteering for Help At Your Door, I am entering into an at-will relationship. This relationship can be terminated at any time at Help At Your Door’s sole discretion. I agree to indemnify, defend and hold Help At Your Door harmless from any claims, liabilities, losses, demands, costs and expenses of any kind. Including reasonable attorney’s fees, which Help At Your Door may hereafter incur, sustain or be required to pay by reason of any negligent act or omission or any intentional misconduct by myself. Agreement: I understand by signing this agreement that I am representing that I have read and understand the above information and agree to uphold its policies and procedures in my volunteer work, as well as the provisions stated above. I also understand that Help At Your Door will continue to update these policies as deemed necessary.
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Date
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Parent/Guardian's Signature (if under age of 18)
Submit
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