Have you in the past or do you use any names other than the one listed on this application? If yes, please list here (Include maiden name) : Have you resided in any state besides WI in the past 5 years?
Yes
No
Have you ever been arrested?
Yes
No
If yes, please list here:
If yes, please list here:
Volunteer Interests What type of commitment would you like to make as a volunteer? □ One-time: For one event/day
List Date and Shift Time: ___________________________
□ Occasionally, as needed
How often would you be available? ___________________
□ Regularly scheduled Short Term: 4-6 months (minimum) □ Regularly scheduled Long Term: 1 year + □ I am interested in an internship with Canopy Center Special Notes: ___________________________________________________________________________ If you are applying for a regularly scheduled volunteer position, please list your volunteer position choices (use Position Information on next page as a reference)” Canopy Center Program
Position
Shift Time
___________________________
____________________________
_______________________________
___________________________
____________________________
_______________________________
___________________________
____________________________
_______________________________
Canopy Center●1457 E. Washington, Madison, WI ● 608-241-4888 ● www.canopycenter.org ● www.danecountycasa.org
Position Information (For regularly scheduled volunteers only) Choose one position to attend weekly. Shifts are filled on a first-come, first serve basis Canopy Center Program
Positions Available
Shift Times
Oasis Sexual Abuse Treatment
Adult Group Co-Facilitator Teen Group Co-Facilitator Youth Group Co-Facilitator Spanish-Speaking Group Co-Facilitator Childcare Assistant
The Parent Stressline is open from 8am-10pm every day of the week. Volunteers are required to take a minimum of one 2-3 hour recurring shift per week within their own availability (please indicate what times work for you) Varies
Time commitment: A minimum of 1 year weekly during cycles (Childcare: 4 month minimum) CASA Time commitment: A minimum of 1 year. Complete 30 hours of training. 10-15 hours a month to the position. Participate in on-going training and court appearances. Parent Stressline Time commitment: A minimum of 6 months with one weekly recurring shift
Parent to Child Time commitment: A minimum of 1 year. Complete training. Participate in on-going training. Administration/Fundraising Time commitment: Negotiable
Family Care Specialist
Office Assistant Special Events Assistant UW Concessions
Varies
1. How did you hear about us? 2. Have you had any experience that relates to child abuse? Yes
No
If yes please explain: 3. Please describe any experience that you have had with severe stress or crisis.
4. Please describe any previous experience or training that relates to the volunteer position for which you are applying:
5. What hobbies, interests, special talents or training can you bring to this position?
6. Please complete this sentence: “When I think of an abusive parent I Canopy Center●1457 E. Washington, Madison, WI ● 608-241-4888 ● www.canopycenter.org ● www.danecountycasa.org
7. Do you speak any languages aside from English? Yes
No
Please list:
8. What mode of transportation would most often be available to you?
Car
Public Transportation
9. When are you available to start?
Please list three references. At least one should be of a professional nature and one a close family member. 1. Professional Reference Name:
Phone:
Relationship:
Email:
2. Family Reference Name:
Phone:
Relationship:
Email:
3. Reference Name:
Phone:
Relationship:
Email:
By signing this form, I authorize Canopy Center to proceed with a background check and to check my references (required of every staff member and volunteer.) I certify that all of the above information is true and correct to the best of my knowledge. (Printing your signature electronically will be considered the same as a hand-written signature.) Signature
Date Thank you for taking the time to complete this application! Our Volunteer Coordinator will be contacting you soon.
OPTIONAL INFORMATION Organizations that provide funding for our programs occasionally request demographic information about our volunteers. Answers to the following questions would be helpful, but not required. Any information you provide will not be used to determine your suitability as a volunteer. Your Gender:
Male
Your Race/Ethnicity:
Female
Your Age:
White Black Asian/Pacific Islander
Under 18
18-59
60+
Hispanic Native American Multi-Race
Do you consider yourself to be a “person with disability” (physical or mental impairment which substantially limits one or more major life activities)? Yes No
Canopy Center●1457 E. Washington, Madison, WI ● 608-241-4888 ● www.canopycenter.org ● www.danecountycasa.org
at 823 W. Lacey Blvd., Hanford, is open during regular business hours from 7:30 a.m. â 4:30 p.m.. except holidays. Once you have received this Live Scan ...
Phone: 215 249-3310 Fax: 215 249-9875. DUBLINBOROUGH.ORG. Please mail to the above address or drop off at the Borough Hall. APPLICANT INFORMATION. Name: Home Address: Home Telephone Number: Cell Phone Number: Number of years residing in Dublin Boroug
... Schools may request a background check on me pursuant to the. Minnesota Child Protection Background Check Act. Background checks are done online, ...
(Exclude minor traffic misdemeanors). If yes, please provide details below. State: County: Date of Offense: / /. Details of conviction: 2. YES NO Have you ever-received deferred adjudication or similar disposition for any federal, state or. municipal
(Exclude minor traffic misdemeanors). If yes, please provide details below. State: County: Date of Offense: / /. Details of conviction: 2. YES NO Have you ever-received deferred adjudication or similar disposition for any federal, state or. municipal
... volunteer within the UK? If you are from the UK, you are free to volunteer. The majority of European Union (EU) citizens are. free to volunteer within the UK. For those from outside the EU you need to check that your visa allows. you to volunteer
Antioch Kids Volunteer Application- One Service.pdf. Antioch Kids Volunteer Application- One Service.pdf. Open. Extract. Open with. Sign In. Main menu.
Commission for a blue card on the volunteer's behalf. ... provided on the blue card application form. ... usual residence is more than 50kms from the business .... Current Credit Card or account card from a bank/building society/credit union (with ..
Jun 7, 2013 - International President Meeting CC Sales Team. å ¨å½æåæ£å¼ ... Endorsement from MC for GEP Application (if needed) ... Feel free to contact:.
SIGNATURE DATE. Please return this form to your student's school or to the. Clintonville Public School District Office. 45 West Green Tree Road, Clintonville, WI 54929. DISTRICT OFFICE USE: Background Check Ordered: ...
MH Volunteer Application w background check and confidentiality verbiage.pdf. MH Volunteer Application w background check and confidentiality verbiage.pdf.
their identity and checking these against the details provided ... Step 1: check the volunteer has completed Part B ... If an identification document is in a former name, an .... Frequently Asked Questions available on the Commission's website at ...
... (section 23), and record the document number/s (if applicable). ... usual residence is more than 50kms from the business address or the .... 1800 113 611. Fax:.
not include championships). My cash or check for $100 per child is attached. Page 1 of 1. Volunteer Form.pdf. Volunteer Form.pdf. Open. Extract. Open with.
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... another state, the District of Columbia, the Commonwealth of Puerto Rico or a ... the Pennsylvania State Police, and the Federal Bureau of Investigation,.
Individuals may volunteer to participate in a street team, at a Come. and Be Counted site, or at the deployment ... Inc, and other local youth service providers works to promote the Youth Count in the community. and facilitate the quarterly event. Pa
development, mother-centered care and the yogic principles of self-less service ... Income Generating Group (WIGG), the Garden Program and relevant activities ... o Provide training and workshops on entrepreneurship, business management ...
Policy number: ... involving drug or alcohol (such as driving under the influence or driving while intoxicated) in the last seven years. ______ ______. 3. I have had no more than three moving violations or accidents in the last three years. ______ __
