Volunteer Application

Volunteer Application

Thank you for your interest in making a difference in the lives of others
Date

MonthDayYear
Date
Full Legal Name

First NameLast Name
Preferred Name (optional)

First NamePersonal Pronoun
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Secondary Phone Number (optional)
Format: (000) 000-0000.
E-mail
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):
Faith-based community (optional):
Name and city
Race - check all that apply (optional):
Emergency Contact:

Full NameRelationshipPhone
Experience - volunteer, paid or internship
Most recent experience

OrganizationActivity/Job titleDates
Additional experience

OrganizationActivity/Job titleDates
If desired, submit resume here:

Cancelof
Skills, hobbies or interests that might be helpful in your volunteer work:

Other
Other
Skills, hobbies or interests
List any languages other than English in which you are fluent:
How did you hear about us?
Other:
Do you need any special accommodations to perform your volunteer duties?
If yes, please explain
Are you applying to volunteer in order to complete required service hours?
If yes, please indicate:

Reason for service hoursNumber of hours requiredDate hours are due
Volunteer positions of interest (check all that apply):
For Shopper and Grocery Helper, which location(s) would you prefer to volunteer at:
If you selected Bloomington, which day(s) works best for your availability:
If you selected Saint Anthony, which day(s) works best for your availability:
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.
Date

MonthDayYear
Date
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:
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.
Date

MonthDayYear
Date
Parent/Guardian's Signature (if under age of 18)
Should be Empty:

Volunteer Application

Experience - volunteer, paid or internship

Certification/Release:

Confidentiality/Publication Agreement