East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us Thank you for your interest in applying to become a volunteer with Johnson and Shelby County VASIA. Serving as a volunteer can be an incredibly rewarding experience for both the individual in need and you. Our first step is to have you complete the Volunteer Application and Authorization for Criminal History Inquiry. With these, you will be providing us more information about yourself and why you would like to volunteer as well as authorizing us to conduct a criminal background check. Once we receive your completed forms, we will contact your references and initiate a criminal background inquiry. Your application is then considered for approval. Once approved, we will talk with you more about expectations, upcoming trainings, and more. You should also feel free to contact me at any time along the way if you have questions. We very much look forward to working with you and are grateful for your interest. All my best, Lauren Rynerson Executive Director 1/2019 1 East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us VOLUNTEER PROGRAM APPLICATION Date of Application_________________ How did you learn about our program?___________________________________________________ PART 1 – PERSONAL INFORMATION GENERAL HISTORY Legal Name_________________________________________ Date of Birth_____________________ Address_______________________________________________ Soc. Sec. #____________________ City/State/Zip__________________________________________ Gender_______________________ Cell #___________________________________ Home #____________________________________ E-mail______________________________________________________________________________ Emergency Contact _______________________________________ Phone#_____________________ EMPLOYMENT / VOLUNTEER WORK HISTORY Present Employer__________________________________________ Date Started________________ Address______________________________________ Title__________________________________ City/State/Zip__________________________________________ Work #_______________________ Job Description______________________________________________________________________ __________________________________________________________________________________ Previous Employer_________________________________________ Date Started________________ Address______________________________________ Title__________________________________ 1/2019 2 East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us City/State/Zip__________________________________________ Work #_______________________ Job Description______________________________________________________________________ __________________________________________________________________________________ Previous Employer_________________________________________ Date Started________________ Address______________________________________ Title__________________________________ City/State/Zip__________________________________________ Work #_______________________ Job Description______________________________________________________________________ __________________________________________________________________________________ EDUCATION / TRAINING / EXPERIENCE High school attended____________________________ Graduation year________□ I did not graduate College or technical/trade school_______________________________________________ Graduation year/Expected graduation year _________ □ I did not graduate College degree(s) and professional/trade Other educational/training programslicenses held ___________________________________________________________________________________ Check any of the following areas where you have training/work experience: □ counseling □ office administration □ criminology/ law enforcement □ law □ public speaking □ education □ health care/nursing □ geriatric care □ psychology/ mental health □ social work □ writing □ news media □ other area that might be helpful_________________________ Describe:___________________________________________________________________________ ___________________________________________________________________________________ 1/2019 3 East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us What language(s) do you speak other than English? _________________________________________ PART 2 – MOTIVATION AND LIFE HISTORY INFORMATION On a separate sheet of paper please write a short summary about your interest in volunteering. -how do you hope to benefit from your experience? -what attracted you to this particular program? -any other information you believe will assist us in reviewing your application PART 3 – PERSONAL REFERENCES Please print the names, addresses, and telephone numbers of three people who have known you for a minimum of two years. Do not include relatives. The references need to be individuals who can address how well you can fulfill the responsibilities of being a volunteer. We will contact your references, so please alert each of them. Name 1_______________________________________________ Phone #______________________ Relationship to you________________________________________ Length of acquaintance________ Address_____________________________________________City/State/Zip____________________ E-mail address _______________________________________________________________________ Name 2_______________________________________________ Phone #______________________ Relationship to you________________________________________ Length of acquaintance________ Address_____________________________________________City/State/Zip____________________ E-mail address _______________________________________________________________________ Name 3_______________________________________________ Phone #______________________ Relationship to you________________________________________ Length of acquaintance________ Address_____________________________________________City/State/Zip____________________ E-mail address _______________________________________________________________________ 1/2019 4 East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us PART 4 – AFFIRMATION AND ACCEPTANCE I hereby affirm that all the answers on this Volunteer rogram Application for Johnson and Shelby County VASIA are true to the best of my knowledge. I hereby authori e The Center for At Risk Elders Inc. to investigate my background to determine my fitness as a potential volunteer. I understand that the information re uested in this application will be used only for the purpose of determining my suitability as a volunteer. urthermore I understand that after the successful completion of my training I will be expected to serve a minimum of six months. If unforeseen circumstances prevent me from fulfilling this obligation I will submit my written resignation to Johnson and Shelby County VASIA as soon as possible. I am aware of the sensitive and confidential nature of the official documents reports and other materials I will examine in my capacity as a volunteer. I promise that I shall hold all pertinent information in strict confidence. I will only discuss the contents of these materials with those persons who are parties to the case and their legal representatives or with persons or organi ations that may be consulted for professional knowledge or expertise. I accept full responsibility for maintaining the confidential and private nature of all records and information. I understand that I am personally responsible and liable for any violation of this statement. Signed_____________________________________________Date___________________ Return completed form to: Lauren Rynerson Executive Director Johnson and Shelby County VASIA East Jefferson Street rd l. ranklin Indiana lrynerson co. ohnson.in.us 1/2019 5 East Jefferson Street ranklin I rd loor lrynerson co. ohnson.in.us Authorization for Criminal History Inquiry I also known as if none so state hereby authori e Johnson and Shelby County VASIA to further search the files and records of the ustice system V records Adult rotective Services records and Child rotective Services records for any criminal history information. I understand that the results of an investigation shall remain confidential but shall be reviewed by Johnson and Shelby County VASIA to determine my suitability for employment and or volunteering. Date_______________________ Applicant’s Printed Name_________________________________________________ Applicant’s Signature____________________________________________________ Date of Birth_______________ Social Security Number_________________________ Gender____________ Race_____________________ Place of birth (city and state)______________________________________________ Present address________________________________________________________ Previous address_______________________________________________________ 1/2019 6