Last Name
First Name
Name of Parent or Guardian if under 18
Email
*If volunteer is under 18 years, the parent or guardian must also complete a volunteer application and agreement form.
Address
Primary Phone
Secondary Phone
Company or Volunteer Group Name
Date of Birth
Driver's License Number
Emergancy Contact
Phone Number
Relationship
When are you available to work (specify hours of availability)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays Only
If expertise explain
List Your Past Volunteer Experiences
Orginzation
Duties
Mo/Yr to Mo/Yr
Orginzation
Duties
Mo/Yr to Mo/Yr
If yes, please describe
BACKGROUND CHECK: DSAHV requires volunteers working with individual consumers to submit to a background check. Criminal conviction does not necessarily bar an applicant from volunteering. The nature of the offense will be taken into consideration before a decision is made. There is no fee on the part of the volunteer for the background check. Screening must be completed before volunteers begin working with consumers
REFERENCES: List two people, not related to you who have knowledge of your qualifications
Name
Phone
Address
Name
Phone
Address
I need the following accommodation(s) to work as a volunteer
As a volunteer for DSAHV, Org., I agree to abide by all applicable rules and regulations of the agency and the New York Division of Developmental Disabilities. I understand that I will receive no monetary benefits in return for my volunteer service and that DSAHV may terminate this agreement at any time without prior notice for any reason. I hereby authorize DSAHV to check my references, and I understand that a criminal background check is required.
I certify that my answers on this application are true and complete and that I have not knowingly withheld any information that might, if disclosed, affect my application unfavorably. I understand that any misrepresentation or omission of facts on this application could be cause for rejection of this application or dismissal.
I understand that after I submit my application, it will be reviewed and my eligibility for volunteer work will be determined. I agree to an interview with a member of the Board of Representatives prior to performing my volunteer role.
I hereby Release and Waive liability against DSAHV, Org., a non-profit corporation, its directors, officers, employees and agents, its successors and assigns, for any injuries or illness that I myself or my dependent may suffer in connection with any volunteer work for DSAHV. Further, I agree that DSAHV, Org., is not liable for any damage to my property or my dependent’s property resulting from volunteer work for DSAHV. I agree that this release is as broad and inclusive as permitted by the laws of the State of New York.
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