ISLAND COUNTY CHAPTER VOLUNTEER APPLICATION
Today’s Date:________ Date of
Birth_________ Age group (14 -17) [] (18 – 24) [] (25 – 55) [] (55+) []
Name: _______________________
Last Name First
Middle
Maiden/Prior
Home Address: _______________________
Apt/Bldg City State Zip
Code
Mailing Address (If Different from Above) __
Suite/Apt/Bldg City State Zip
Code
Home Phone ___________________Business Phone _______________Cell
Phone ________Fax Number __________E-Mail Address__________
Employer: Occupation
Employer Address Suite City State Zip Code
*Emergency Contact: Name *Phone: Relationship
Name
Street Address Apt/Bldg City State Zip Code
Experience (Please relate
any experience you feel would help make you a successful Red Cross volunteer.)
Education (Students
indicate current school)
Institution Name City/State Degree/Major Date Attended/Anticipated
Graduation Date
Fluent Language Skills
(Include sign language)
Other
Skills (Computer, etc.)
Volunteer Opportunities (Please check all that
interest you)
[]
Health and Safety [] Speakers
Bureau [] Other [] Fund Raising [] Disaster Services
[] Special Events/
Projects [] Public Relations [] Administrative/Office
Availability []
Short Term []
Long Term
[] Weekdays [] Evenings []
Weekends
Previous Red Cross Experience
Have you ever worked as a Red Cross employee? (If yes,
give position, dates ,and location.)
Have you ever worked as a Red Cross volunteer? (If
yes, give function, dates, and locations.)
Have you ever held any Red Cross certification? (If
yes, please list.)
A “yes” answer to the following italicized questions
does not necessarily disqualify an applicant.
Are you licensed to operate a motor vehicle in this
state?
Has your license to operate a motor vehicle ever been
revoked? If yes, please explain.
Have you ever been bonded?
Has you bonding ever been revoked? If yes, please
explain..
Have you been convicted of a felony or misdemeanor
within the past 24 months, which resulted in imprisonment? If yes, please
explain.
Have any of your Red Cross certifications ever been
revoked? If yes, please explain.
Why do you wish to volunteer with the American Red
Cross (optional):
I do hereby give the American Red Cross permission to
inquire into my educational background, references, driving record, police
records, employment, and/or volunteer history. I further give permission to the
holder of any such records to release the same to the American Red Cross.
I do hereby hold the American Red Cross harmless from
any liability, whether civil or criminal ,that may
arise as a result of the release of this information about me. I further hold harmless any individual agency,
business, or corporation that provides information or documents to the
above-named American Red Cross unit. I
understand that the American Red Cross will use this information as part of its
verification of my volunteer application and periodically for evaluation
purposes.
Signature:____________________________________________Date:__________________________________
STATISTICAL
INFORMATION
The American Red Cross, in recoginition
of its responsibility to employees, volunteer, and the community it serves,
reaffirms its policy to assure fair and equal treatment in all of its
practices, for all persons. The American
Red Cross will not discriminate on the basis of race, color, religion, sex or
notional origin, or against any qualified handicapped individual, disabled
veteran, or veteran of the
While completion is optional, it would be most helpful
to us as we monitor the complete record of our program.
Gender: M
[] F []
Veteran: Yes[] No []
Disabled: Yes[] No []
Ethnic group: Black
[] Hispanic [] Native Hawaiian/Other Pacific [] Asian []
White
[] American Indian/Alaskan Native [] Other (Describe):
_______________________________
Volunteer
Applicant Date Application was submitted
Please mail to
Disclosure and Consent Form for Release of Information
Volunteer Application
It is the policy of the
American Red Cross, Island County Chapter, to conduct criminal record checks on
all individuals interested in volunteering with the chapter. Volunteers in many programs work unsupervised
with people who are considered “vulnerable”.
For this reason, criminal background checks are necessary to protect the
client, the agency, and the volunteer.
The criminal background check
will only be used to establish whether or not a potential volunteer has a
criminal record within the State of
This request for a criminal
history is done through the Washington State Patrol, and is free of charge to
non-profit organizations. All
information obtained will remain confidential.
In the event of a criminal
record, you will be contacted and given an opportunity to discuss your
volunteer placement. If the Washington
State Patrol reports no criminal record, you will be able to begin your
volunteer assignment immediately.
To conduct the criminal
record check, the following information is required.
·
First name, M.
I., last name:_____________________________________________________________
·
Date of birth:
mm/dd/yyrr:_______________________________________________________________
·
Social Security
#_______________________________________________________________________
·
Have you been
convicted of a crime in the State of
I,__________________________________________,
have read the above statement and give my permission to the Washington State
Patrol to send all criminal record information pertaining to me to :
American Red Cross
1010
___________________________________ _________________________________________
Signature Date
___________________________________ _________________________________________
Signature of parent if
volunteer is under 18 Date
Updated