Volunteer Application

PERSONAL INFORMATION

Name(*Required)

First Last

Address(*Required)

Street Address Address Line 2 City State ZIP Code

Email(*Required)

Phone (Day)

Phone (Evening)

Phone (Mobile)(*Required)

Age(*Required)

Known Food Allergies

Emergency Contact Name(*Required)

Emergency Contact Phone Number(*Required)

Employment

Are you currently employed?(*Required)

Yes

No

Education

Tutors & mentors must be currently pursuing or already have a post-secondary degree.

Name of School(s)(*Required)

Field(s) of Study(*Required)

Degree(s) Received(*Required)

Is your participation part of a class?(*Required)

Yes

No

Instructor’s Name(*Required)

Criminal Record(*Required)

Have you ever been convicted of a violent crime including, but not limited to assault or any crime involving children (including sexual abuse/molestation, abuse or neglect)? Are you the subject of an indicated child abuse and maltreatment report on file in any state?

Yes

No

Employment Record(*Required)

Have you ever been terminated, suspended, placed on probation, reprimanded, or otherwise penalized by an employer for child abuse and/or maltreatment in this state or elsewhere?

Yes

No

Please provide two references

Reference One Name(*Required)

First Last

Reference One Address(*Required)

Street Address Address Line 2 City State ZIP Code

Reference One Phone(*Required)

Reference One Email(*Required)

Reference One Relation(*Required)

Reference Two Name(*Required)

First Last

Reference Two Address(*Required)

Street Address Address Line 2 City State ZIP Code

Reference Two Phone(*Required)

Reference Two Email(*Required)

Reference Two Relation(*Required)

Disclaimer and Release from Liability (all potential volunteers must complete this section)(*Required)

I understand that as a volunteer with the YWCA Metro St. Louis the nature of volunteer activities may involve physical activity, contact with unfamiliar people, and other potential risks of injury. Knowing this, I hereby assume the risk for any accident or injury, to person or property, which I may sustain in conjunction with my participation in the volunteer position. In addition, I hereby release and discharge the YWCA and any of its directors, officers, employees, affiliates, or successors from any and all liability and responsibility for such action or injury.

To the best of my knowledge all statements set forth in this application are true. I authorize the YWCA Metro St. Louis or its agents to undertake any investigation it deems appropriate in connection with this application. This includes, but is not limited to contacting all listed references, completing state and/or national background check, and a driver record check through the Missouri State Highway Patrol. I understand that misrepresentation or material omission from this application may result in my disqualification for a position with YWCA and may be the basis for termination of my services and/or further legal action to the extent allowable by law.

By typing your name below, you accept the terms described above:

Today’s Date(*Required)

Release Agreement(*Required)

I further agree that my picture, name and/or representation may be used for promotional media including participant and volunteer recruitment efforts, program and agency promotion, and any other agency related purpose.

By typing your name below, you accept the terms described above:

Today’s Date(*Required)

Phone

This field is for validation purposes and should be left unchanged.