Kids Hope Volunteer Registration

Please take the time to fill the form out completely. Thank you! 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