Volunteer Application

Today's Date*

MonthDayYear

Preferred Volunteer Location*

Glencliff (149 Antioch Pike)Tusculum (4908 Aquatic Rd)

Full Name*

First NameLast Name

Date of birth*

MonthDayYear

Social Security Number*

No regular program volunteer shall be younger than 15. Exceptions must be made only by the Director of Operations or Executive Director and will only be made wherein there is specific extraordinary reason, such as advanced academic promotion (i.e. wherein the teen has had early promotion to a higher grade).

First time or one time volunteers, especially those not interacting with our clients may be exempted from these requirements as determined, with good reason, by the Director of Operations or Executive Director.

Volunteers coming as a group (e.g. church youth groups) may include non-adults, ages 12 and higher.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell/Home Phone*

Area CodePhone Number

Best time to call*

Work Phone

Area CodePhone Number

E-mail*

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

Marital Status*

Spouse Name*

First NameLast Name

Home Church & Pastor

Current place of employment

Position held

Have you ever been convicted of any type of criminal or abusive behavior?*

YesNo

Please explain*

Please list any special skills you may have, to better help us place you as a volunteer in our program

If applicable, name of School currently attending

Projected date of graduation

MonthDayYear

If applicable, degree sought

Insurance Company*

Policy Number*

Please provide at least three character references:

Reference 1 - Name*

1 - Phone Number*

1 - Relationship*

Reference 2 - Name*

2 - Phone Number*

2 - Relationship*

Reference 3 - Name*

3 - Phone Number*

3 - Relationship*

Reference 4 - Name

4 - Phone Number

4 - Relationship

A personal relationship with Jesus Christ is not necessary to volunteer at Cottage Cove, though it may restrict what aspects you will be allowed to lead or assist with. For example, and needless to say, without such you would not be teaching Bible Study or leading in prayer. (Type N/A in the text fields asking for description)

Do you have a personal relationship with Jesus Christ?*

YesNo

Briefly describe your relationship with Jesus Christ*

Briefly describe your salvation experience*

Will commit to pray on a regular basis for the work you do at Cottage Cove?*

YesNo

Have you ever worked as a volunteer before?*

YesNo

Please describe when, where, and in what capacity*

Why do you want to volunteer at Cottage Cove?*

By signing this form I acknowledge that should a medical emergency arise and in the event that I am unable to authorize such treatment, I hereby authorized Cottage Cove staff to secure any medical treatment, or transportation, they deem necessary. I understand that I am responsible for any or all cost involved in such transportation or treatment.

By signing this form, I agree to to abide by all rules established concerning proper conduct for volunteers (as posted online: www.cottagecove.org, or within the Cottage Cove facility), including usage of cell phones, appropriate footwear, jewelry, and reasonably modest apparel. Should my failure to follow these rules cause harm to myself or others, I hold Cottage Cove free from any liability. In volunteering at Cottage Cove, I consent to unremunerated use of my image in photographs, video, web or promotional materials. I also acknowledge that Cottage Cove will contact my references and perform background checks on me as necessary.

In my choosing to participate in any activity at Cottage Cove, and particularly those with physical exertion or motion (including games and playground), I acknowlegde that I understand the risks (expressed or not) and that I have the physical stamina and dexterity to accept such involvement.

I also signifiy that I have read and will abide by Cottage Cove's Employment Policy Concerning Age and Accoutability. This policy may be read and printed from: www.cottagecove.org/employmentpolicy.pdf. If I am a viewed a minor by state law, I also certify that my parent(s) and/or guardians are aware of my involvement, the provisions herein, and have given their assent to such participation with all these provisions.

Signature

Type full name*

Cottage Cove Volunteer Application

Please sign by drawing (if possible) and by typing full name (with or without drawn)