OFFICE USE ONLY
Date received:
/
/
.
Location: □ Jefferson
□ Junction City
□ The Club
□ Plover
□ Almond/Bancroft
Volunteer Application Form
Background check complete:
/
/
**The information requested is necessary to perform a background check before your application can be considered for volunteer
opportunities. Your application WILL NOT BE CONSIDERED unless all fields are completed.**
Name:
DOB:
Address:
Social Security #:
City:
Home Phone:
State:
Work Phone:
Zip:
Email
Where did you learn about our volunteer opportunities?
Are you seeking to volunteer in order to satisfy court-ordered community service?
DEMOGRAPHIC INFORMATION (optional) This information is used for statistical data in applying and/or reporting for grants.
I am:
Male
Female
Ethnicity:
Caucasian
Asian
Other
African American
Hmong
Hispanic
Native American
SKILLS AND EXPERIENCE
What is your educational background?
What sorts of hobbies, interests, and activities do you enjoy?
What is your occupation?
Do you have any past or present volunteer experience? If yes, please describe.
INTEREST INVENTORY
This section will help you determine what volunteer activities you might like to participate in. Please check the area(s) that interest
you. Check as many or as few as you like!
I would enjoy:
Music Leader/Assistant-Which type(s)?
Tutoring-Which subjects?
Sports Coach/Assistant-Which sport(s)?
Arts and Crafts Activity
Instructor/Assistant Helping a Child Use a Computer
Listening to a Child Read
Playing Board Games
Assisting with Fundraising
Leading a Recreational Activity
Acting as a Mentor for Teens
Leading a Discussion Group
Assisting with Office and Clerical Work
Chaperoning a Field Trip
Activities not listed above that I am interested in:
Continued….
Boys & Girls Club of Portage County • Stevens Point, WI 54481 • 715-341-4386
.
PREFERENCES IN VOLUNTEERING
Members of the Boys & Girls Clubs are ages 6 to 18 depending on the site. Which age groups would you most enjoy working with?
(check as many as you like)?
6 to 8 years old
9 to 10 years old
11 to 12 years old
13 to 15 years old
16 to 18 years old
No preference / all ages
AVAILABILITY
This section will help determine the best days and times for your volunteer activity. Please mark all days and times you will be
available to volunteer. (The Boys & Girls Club is not open on weekends)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Are there any physical limitations or are you under any course of treatment that might limit your ability to perform certain types of
work?
ADDITIONAL INFORMATION AND RELEASE FOR BACKGROUND CHECK
(Please check the applicable response)
Have you ever been convicted of a criminal offense?
Yes
No
Have you ever been convicted of child abuse or neglect?
Yes
No
Has your license ever been suspended or revoked?
Yes
No
Are there any other facts or circumstances involving you or your
background that would call into question your being entrusted with the
supervision, guidance and care of young people?
Yes
No
Please use an additional sheet of paper to explain any “Yes” response)
CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT
I certify that all information submitted in this volunteer application, interview, or other information is true and complete, and that I
have not knowingly withheld, nor will I withhold, any information that would effect my application or volunteer employment. I
understand the employer is under no obligation to consider or reconsider my application at anytime and that acceptance of this
application does not constitute an offer of volunteer employment and that falsification of this application will be grounds for
elimination from further consideration, or if employed, for dismissal at anytime.
Signature
Date
During the application process and at any time during the tenure of my volunteer employment with the Boys & Girls Club of Portage
County, I give permission to the Boys & Girls Club of Portage County to obtain records that would, or may have any bearing on
volunteering at the Boys & Girls Club of Portage County. These records may include social media and criminal record checks as
well as any records in which I am a complainant, victim, defendant, or mentioned.
Signature
Date
Boys & Girls Club of Portage County • Stevens Point, WI 54481 • 715-341-4386