Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Birthdate * MM DD YYYY Do you hold a valid Wisconsin Driver/s License? * Yes No Which opportunities are you interested in? * Life Skills Hannah's Caring Closet Cleaning Gardening Mentor Special Projects Childcare Other/Unsure General availability (days & times): Desired Volunteer Location * Marshfield Wisconsin Rapids Both Volunteer Pledge I hereby agree that as long as I am associated with The Hannah Center or am representing the organization in any capacity, I will adhere to all policies and procedures of the Hannah Center. I will treat all information that I obtain on individual clients/residents of The Hannah Center or any organization operating on The Hannah Center premise as completely confidential, both during and after my association with The Hannah Center. As a volunteer for The Hannah Center, my life is an example to the young women I may be guiding. Therefore, I will lead my own life according to the values which The Hannah Center attempts to impart to its residents. Finally, I will treat all information that I obtain on individual clients/residents of The Hannah Center as completely confidential, both during and after my association with the Center. Volunteer Pledge Acceptance * Yes No THE FOLLOWING MUST BY COMPLETED BY ALL EMPLOYEES, VOLUNTEERS AND BOARD MEMBERS. Sexual misconduct by personnel (including officers, employees and volunteers) of The Hannah Center while performing the work of The Hannah Center is contrary to Christian principles and is outside the scope of the duties and employment of all personnel. *All persons who are involved with The Hannah Center or The Hannah Center events must answer all of the following questions. 1. Has a civil or criminal complaint ever been filed against you alleging physical or sexual abuse? * Yes No If yes, give a short explanation of the complaint. (Please indicate the date, nature and place of the incident leading to the complaint, where the complaint was filed and the disposition of the complaint.) 2. Have you ever suspended or terminated your employment or had your employment suspended or terminated for reasons relating to allegations of physical or sexual abuse? * Yes No If yes, give a short explanation of the allegations. (Please indicate the date, nature and place of the allegations, the disposition of the allegations and your employer at the time including your employer's name, address and telephone number.) 3. Have you ever been suspended and/or had any license or certificate suspended or revoked for reasons relating to allegations of physical or sexual abuse? * Yes No If yes, give a short explanation of the allegations. (Please indicate the date, nature and place of the allegations, the disposition of the allegations and the licensing or certificate granting agency, including the agency's name, address and telephone number.) References Please list three persons who can provide character references relating to your fitness for working with young people. These should not be family members or past or present employers. Name * First Name Last Name Phone * (###) ### #### Relationship * Name * First Name Last Name Phone * (###) ### #### Relationship * Name * First Name Last Name Phone * (###) ### #### Relationship * The information provided in this form is correct and to the best of my knowledge. I understand that by checking the agreement box below, and submitting this form, I authorize verification of this information through communication with any person or organization named herein. I release from liability any person or organization which provides such information. I agree * Yes Thank you! Volunteer Application
