THRIVE-RESPITE VOLUNTEER APPLICATION

RESPITE VOLUNTEER APPLICATION

Pine Summit Baptist
FULL LEGAL NAME *

First NameLast Name
Date of Birth *

MonthDayYear
Date
GENDER*

MALEFEMALE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Emergency Contact*

First NameLast Name
Relation*
Home Phone*

Area CodePhone Number
Cell Phone *

Area CodePhone Number
Do you have a disability?*

YesNo
If yes, please describe, *
Are you employed?*

YesNo
Employer*
Position *
Religious affiliation *
Church you attend (If applicable)
CPR Certified *

YesNo
If yes, through what agency?
When does it expire?

MonthDayYear
Date
Previous respite volunteer?*

YesNo
If yes, where?
Previous Joni and Friends volunteer?*

YesNo
If yes, when and where?
My experience with children with special needs includes: *
NONE REQUIRED
I am comfortable working with children ages (check all that reply)*

0-1(infant)2-4(toddler)5-78-1011-1212+ALL
Have you ever been convicted of a crime involving children and/or youth?*

YesNo
Have you ever been convicted of child abuse, sexual abuse, or sexual harassment?*

YesNo
I hereby confirm that all the information above is true and correct. I authorize Pine Summit Baptist to procure a consumer report (background check or known as an investigative consumer report in Florida. I give my consent that photographs, interviews, and audio/video recordings during the respite event may be used by the host church for training, promotion, and fundraising.
I have read the above statement and agree to the terms designated*

Clear
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