Office Use Only:
Record Date
ICHAT
DHS
TRAINING
HANDBOOK
BINDER
235 Straight NW
Grand Rapids, MI 49504
P: 616.233.9370 F: 616.233.9371
www.bgcgrandrapids.org
Volunteer Application
CONTACT INFORMATION
Last Name
First
Street Address
M.I.
Apt #
City
State
Zip
Phone
E-mail Address
How often do you check E-mail?
Best Contact Method? (Phone or E-mail, day and time)
Daily
Every 3-5 days
Rarely
Emergency Contact
Phone
Relationship to Volunteer
PLACEMENT
Interests (Please circle all that apply)
Location (Please circle all that apply)
Day(s) Available
Art Room
Education & Technology
Sports & Fitness
Recreation & Games
Teen Development
Administrative Office
Special Events
Seidman
Steil
Paul I. Phillips
Camp O’Malley
Monday
Wednesday
Thursday
Friday
REASONS FOR APPLYING
Future enrichment
Future job reference
Resume building
Being around kids
Intern
Tuesday
Court Ordered
Skill building
Future employment
With a group; Which one?
Coaching; What sport?
Date
REFERENCES
Please provide the names of two references not related to you or staff member:
1.
Name
Relationship
Phone
2.
Name
Relationship
Phone
BACKGROUND
Have you ever pled “guilty” or “no contest” to, or been convicted of a crime?
Yes
No
If yes, please provide dates and details below.
Boys & Girls Clubs of Grand Rapids shall conduct criminal background checks yearly to all volunteers who have direct
contact with children. Name-based record searches may be used but shall, at a minimum, (a) verify the person’s identity
and legal aliases, (b) provide a national Sex Offender Registry search, and (c) provide a national criminal record search.
Such checks shall be conducted prior to volunteering. All background check findings shall be considered when making
volunteer decisions. A person will be ineligible for volunteer service if the person:
1) Refuses to consent to a criminal background check
2) Makes a false statement in connection with such criminal background check,
3) Is registered, or is required to be registered on a State or National sex offender registry,
4) Has been convicted of a felony consisting of:
a)
Murder
b) Child abuse
c)
A crime against children, including child pornography
d) Spousal abuse
e)
A crime involving rape or sexual assault,
f)
Arson or
g)
Physical assault, battery,
5) Has been convicted of a drug related offense committed within the last 5 years.
With respect to convictions for crime not listed above, any applicant with such a conviction shall be evaluated on an
individual basis to determine whether they should be excluded from consideration based on the conviction.
I understand that BGCGRYC performs yearly criminal background checks through the GRPD and I give my
permission for BGCGRYC to conduct such a criminal history check. I affirm that all information contained on
this application is true and complete and that any falsification or misrepresentation may result in my nonacceptance or dismissal as a volunteer.
SIGNATURE: X __________________________________________ DATE: _____/_____/_____
ICHAT Background Check
Please complete the fields below
Last Name
First
M.I.
Date of Birth
Driver’s License/ID Number
Date
Please list any other aliases or maiden names in the space below
Sign as appropriate below…
With my signature, I give permission to the Boys & Girls Clubs of Grand Rapids Youth Commonwealth
(BGCGRYC) to confirm my personal data on the Internet Criminal History Access Tool (ICHAT), as
maintained by the Michigan State Police, for the purpose of employment and/or volunteering at GRYC,
including all of our entities.
Signature:
Date:
/
/
Note: The Internet Criminal History Access Tool (ICHAT) allows the search of public records contained in the
Michigan Criminal History Record maintained by the Michigan State Police, Criminal Justice Information
Center. All felonies and serious misdemeanors that are punishable by over 93 days are required to be
reported to the state repository by law enforcement agencies, prosecutors, and courts in all 83 Michigan
counties.
BGCGRYC will not discriminate against any individual or group regardless of political affiliation, race, color,
national origin, marital status, sex, religion, creed, age, pregnancy, disabilities or any other protected status.
Boys & Girls Clubs administer a program designed to recruit, select, and promote employees and volunteers
on the basis of their relative ability, knowledge and skills.