Board Participation Application & Questionnaire PERSONAL INFORMATION Social Security #

Name (last, first) Address

Phone #

City State/ Zip Are you over 17 years of age? [ ] Yes [ ] No Have you ever been convicted of a crime? [ ] Yes [ ] No

Alt#/Cell# Best Hours to reach you? If Yes, please give details below:

Conviction of a crime does not necessarily disqualify and applicant from participation DESIRED VOLUNTEER PARTICIPATION  PARENT REP  COMMITTEE MEMBER  GENERAL BOARD MEMBER Interest Areas: Previous Experience, Skills or Training that would be of assistance to the board: GENERAL INFORMATION Have your ever applied to this company before? [ ] Yes [ ] No If yes when? Have you ever worked for this company before? [ [ Yes [ ] No If yes when? ___________________ Reason for leaving? VOLUNTEER HISTORY Please list your previous volunteering experience, starting with the most recent. From Mo/Yr

To Mo/Yr

Employer Name, Complete Address & phone #

Supervisor’s Name, Title, Ph, e-mail

Principle Duties

Can we contact?

PERSONAL REFERENCES NAME

COMPLETE ADDRESS & PHONE # (e-mail address if available)

BUSINESS

YEARS ACQUAINTED

I understand and agree that I may be required to undergo fingerprinting and/or a background check as a condition of volunteering for this organization. I agree to comply with all OCFS regulatory requirements for volunteers working in this organization and to conduct myself in a manner that is consistent with the expectations of the organization with regard to my interaction with the staff members, and the families they serve. I certify that the facts contained in this volunteer application are true and complete to the best of my knowledge and I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous volunteer activities and any pertinent information they may have, personal or otherwise and release all parties from all liability for any damage that may result from furnishing the same to you.

Signature:

Date: