VOLUNTEER APPLICATION FORM

PURPOSE

Please briefly describe the purpose of your application to volunteer. *

CONTACT INFORMATION

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Email Address *

CellPhone Number *

Alternative Phone Number *

EDUCATION

High School *

Year Graduated *

City *

State *

Post-Secondary (Start from the most recent.)

	School	Degree	Major	Year
1)	School	Degree	Major	Year
2)	School	Degree	Major	Year
3)	School	Degree	Major	Year

List all awards, honors or achievements that you want us to know. Please let us know when it was awarded to you and from which organization.

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EXPERIENCE

Please list and describe all previous work experience that is related to the volunteer work that you would like to do. Please include date, place and/or organizations. Please use 1 box for each volunteer experience.

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VOLUNTEER ASSIGNMENT

Please list the language/s that you speak? Please use 1 box for each language.

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Please let us know what times of the day you are available to volunteer.

	From (time)	To (time)
Monday	From (time)	To (time)
Tuesday	From (time)	To (time)
Wednesday	From (time)	To (time)
Thursday	From (time)	To (time)
Friday	From (time)	To (time)
Saturday	From (time)	To (time)
Sunday	From (time)	To (time)

BACKGROUND CHECK

IMPORTANT! It is a 21st CCLC program requirement that all employees, service contractors and volunteers who work with the program have approved criminal background check. The center will run the following background check before hiring:

NC Sex Offender Database and National Sex Offender Database
Statewide Criminal Background Check including all states in which the employee or volunteer lives or has lived for the previous five (5) years.

Please note that individuals convicted of any kind of felony and/or any offense involving sexual or physical abuse/neglect against a child are strictly prohibited from working with the 21st CCLC Program.

Please type your initial across each statement.

	Initial
1) I authorize Sipnayan Math Center and Afterschool Program LLC to conduct an investigation of my background using the NC Sex Offender Database and the National Sex Offender Database.	Initial
2) I authorize Sipnayan Math Center and Afterschool Program LLC to conduct a national criminal background check to include all states in which I live or have lived in the past 5 years.	Initial
3) I understand that if I was found convicted of any kind of felony and/or any offense involving sexual or physical abuse/neglect against a child, I will not be eligible to work with the 21st CCLC Program run by Sipnayan Math Center and Afterschool Program LLC.	Initial
4) I understand that my social security number is necessary to run an accurate criminal background check. For the security of my personal information, I understand that this information will not be collected online. Therefore, I agree to provide my Social Security number via phone to Sipnayan's HR representative.	Initial

First Name *

Last Name *

MI *

List all other names that were used previously. Please use one box for each former name.

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Date of Birth * +

Driver's License # *

DL State *

Expiration Date * +

List ALL addresses in the last 5 years starting on the current address.

	Street	City	State	From-To (Year)
1)	Street	City	State	From-To (Year)
2)	Street	City	State	From-To (Year)
3)	Street	City	State	From-To (Year)

Volunteer Signature *

clear

Thank you for volunteering your time to help us create a brighter future for our youth and their families.

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