THRIVE-RESPITE VOLUNTEER APPLICATION

RESPITE VOLUNTEER APPLICATION

Pine Summit Baptist
FULL LEGAL NAME

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
GENDER
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?
If yes, please describe,
Are you employed?
Employer
Position
Religious affiliation
Church you attend (If applicable)
CPR Certified
If yes, through what agency?
When does it expire?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous respite volunteer?
If yes, where?
Previous Joni and Friends volunteer?
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)
Have you ever been convicted of a crime involving children and/or youth?
Have you ever been convicted of child abuse, sexual abuse, or sexual harassment?
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
Should be Empty: