Date

Date _________________

Volunteer Application Name

(Please Print)_____________________________________

Birthday _____________________ (Month & Day, year optional)

Spouse Name _______________________________________ Local Address _______________________________________________________________________ City __________________________________ State __________ Zip Code _____________________ Phone #s (Hm) __________________ (Wk)_____________________(Other)____________________ E-mail address _______________________________________________________________________ Occupation _________________________________________________________________________ Driver Lic. ________________ Auto Ins. & Policy Number ________________________________ How did you learn about Stepping Stones for Women? ___________________________________ Please describe any prior volunteer experience that may pertain to your volunteering at Stepping Stones:

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ What is your preferred area of volunteer work at Stepping Stones for Women? Please number in order of preference 1-5

        

Office assistance (data entry, word processing, filing, mailings, copying) Transportation (i.e. take residents to and from various appointments) Childcare (while residents are in classes or at other appointments) Mentor Mom (one-on-one relationship, social outings, etc.) Spiritual Coach/Partner (Church attendance, Bible study) Fundraising and/or special event planning Maintenance Tutoring Teaching (Please circle area of expertise: spiritual classes, infant care,

parenting, life skills, job skills, cooking, sewing, crafts, health/hygiene)

Other___________________  Other (ex. Church Liaison)______________________________________________ Sunday

Monday

Day & Times Available Tuesday Wednesd Thursday Page 1 of 3

Friday

Saturday

ay

Please list any major medical problems or physical limitations you may have: _____________________________________________________________________________________ _____________________________________________________________________________________ Have you had a TB test in the last 12 months? Yes If yes, please indicate: Date: ____________________

If no, are you willing to have TB test?

No

Result: _________________

Yes

No

Please answer the following questions: (An answer of yes on any of the following questions, does not automatically exclude you from the program)

Have you ever been convicted of a crime (not including a minor traffic offense)? Yes No If yes, please indicate offense(s) and date(s):

_____________________________________________________________________ _____________________________________________________________________ 1. Are you currently using illegal drugs? Yes No

_____________________________________________________________________ _____________________________________________________________________ 2. Have you ever been arrested or convicted of a drug or alcohol-related crime? Yes No If yes, please indicate offense(s) and date(s):

_____________________________________________________________________ _____________________________________________________________________ 3. Have you ever been arrested or convicted of the charge of child abuse, or of actual or attempted sexual molestation of a minor. Yes No If yes, please indicate offense(s) and date(s):

_____________________________________________________________________ _____________________________________________________________________ 5. Have you ever been arrested for or convicted of a crime involving violent behavior? Yes No If yes, please indicate offense(s) and date(s):

_____________________________________________________________________ _____________________________________________________________________ Page 2 of 3

Are you currently involved in a local church?

Yes

No

Name of Church: _______________________________________________________________ Address: ______________________________________________________________________ Please explain your involvement: _________________________________________________ _______________________________________________________________________________ Please briefly describe your spiritual journey: ___________________________________________________________________________________

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Please list the names and phone numbers of two (2) references who know you well (example, pastor, friend, co-worker. Please exclude relatives.) 1) Name __________________________________

Phone (h) ___________________________

2) Name __________________________________

(w) ___________________________ Phone (h) ___________________________ (w) __________________________

*For Office Use Only Please! Thank you! NOTES: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Date of Tour/Interview: _______________________ Staff Member: ___________________ Photo Copies of, Drivers License Auto Insurance Confidentiality Statement Signed: Y N Photo Copies of Fingerprinting: Y N

TB test

Primary Volunteer Position: ____________________________________________________ Secondary Volunteer Position: __________________________________________________ Entered into Database:

____________________________ (name) Page 3 of 3

____________________________ (date)

Page 4 of 3