First Name

 

Middle Name

 

Last Name

 

Day Time Phone

 

Address

 

Email

 

If you have lived at your current address less than seven years, provide information on all adresses during that period.

 

Past Addresses

 

List all other names by which you have been known.

 

Date of Birth

 

Diver's License #

 

Length of membership/attendance at church

 

T-Shirt Size

Small
Medium
Large
XLarge
2X
3X

 

Emergency Contact Name

 

Emergency Contact Relationship

 

Emergency Contact Phone #

 

Are you 18 years of age or older?

Yes
No

 

Have you ever been convicted of, pled guilty to, or pled no contest to a crime other than a minor traffic violation?

Yes
No

 

If so, please explain:

 

References (Required for mentors and substitute mentors. Optional for prayer partners, unless they will be having regular contact with children) List at least two references from places of employment or prior volunteer service, especially concerning previous work with youth. References must meet the following criteria: must be over age 18; must not be a relative; must have known you for at least one year.

 

Reference #1

 

Reference Name

 

How do you know this person?

 

Length of time you have known this person

 

Reference Address

 

Reference Home Phone

 

Reference Work Phone

 

Reference Cell Phone

 

Reference Email

 

Reference #2

 

Reference Name

 

How do you know this person?

 

Length of time you have known this person

 

Reference Address

 

Reference Home Phone

 

Reference Work Phone

 

Reference Cell Phone

 

Reference Email

 

Please Indicate for what role you would like to volunteer:

Regular Mentor
Substitute Mentor
Prayer Partner
Occasional Special Projects

 

Please list previous volunteer activities

 

Volunteer Pledge

 

If I am assigned as a school volunteer, I accept the responsibility to serve in support of the educational program and supplement the work of the professional staff, under their guidance. I understand that it is important to be reliable, channel suggestions constructively, keep information confidential and comply with school rules. As a member or regular attender of Central Wesleyan Church, I agree to be accountable to the leadership of this church regarding my Christian life and witness according to the biblical witness of this church and in all aspects of conduct and performance related to this volunteer position.

 

I understand that a very positive benefit, when working with students, is the relationship developed between the volunteer and student. I take seriously the relationship that will be formed. I agree to a criminal history check (national and/or state level). My signature on this form authorizes you to make such checks and to disclose results to both church and school personnel as part of the KIDS HOPE USA program.

 

Date

 

I accept and agree to the Volunteer Pledge