The Peacemaker Program Volunteer Application

The following information will be regarded as strictly confidential.

Volunteer Information

 

Name:      Gender: Male     Female 

Address:      City, State, ZIP:

Home Phone Number:                 Social Security Number:  

Emergency Contact Person:       Phone #:  

Employer:              Position:  

Type of Organization:         Length of time employed:  

Business Address:     City, State, ZIP:  

Phone:                            May we phone you at work? Yes     No 

Do you have an e-mail address? Yes     No                     If yes, e-mail address:  

How do you wish to volunteer (check all that apply)?

CASA (Court Appointed Special Advocate)

Child Custody Advocate    

Ropes Course/Adventure Program

Mediation

I'm not sure yet; please send me some information

Other:

 

School Name	Field of Study	Degree	Date

 

 

Organization	Position	Duties	Date

List any other specific qualifications/skills you have which would be of value to this program:

Have you ever been convicted of a crime? Yes     No (note: a conviction does not necessarily bar you from acceptance to this program)

If yes, please explain:

Can you commit a minimum of 1 year to the program? Yes     No

Please list three references below (e.g. supervisors, professors, mentors, etc.  Do not list relatives.)  In order to prevent delay in processing your file, be sure to complete all of the information requested

1. Name:     Relationship:

Address:    Phone:

2. Name:     Relationship:

Address:    Phone:

3. Name:     Relationship:

Address:    Phone:

How did you hear about the Peacemaker Program?  Please check all t:at apply, and supply details where needed.

Newspaper        Television        Radio        VolunteerMatch/Internet        Agency Event        Employer/Work

Board Member:         Current Volunteer:         Sign/Poster at:

Peacemaker Employee:         Court/Other Agency Employee:        

Other/More Information:  

I understand that by submitting this application, I authorize a criminal records and a child abuse state central registry check to be made concerning my suitability as a volunteer.  In addition, the information in this application and otherwise obtained will be used only for the purpose of determining my eligibility as a volunteer.  All information will be held in confidence. Criteria used in the selection of volunteers will be such as to insure that the individual is able to meet the responsibilities of a Peacemaker Program, Inc. volunteer.   No individual will be rejected on the basis of race, color, religious creed, national origin, sex, age or marital status. 

By transmitting this form, I hereby attest that all information given in this application is true to the best of my knowledge.  Applicant's Initials: