Fill out completely and submit

Program Volunteer Application



Last Name
First Name
Middle Name
Other Names You Have Been Known As
Social Security Number
Date of Birth
Present Address (Number / Street / Apt.)
City
State / Zip
Home Telephone Number
Business Telephone Number
E-mail
Type of Service Opportunity Sought: (Please check all that apply)
    Other:  
Consent and Release for Background Screen:

I understand that as a part of the selection process for volunteers, it will be necessary for the Noyes Home for Children to conduct a criminal background check and child abuse / neglect check to determine if it is appropriate for me to provide volunteer or special service to the children of the home. By submitting this signed application, I am giving permission for the Noyes Home to use my identifying information including my name, date of birth and social security number for the purposes of conducting said background investigation. I further agree to follow all policies of the Noyes Home concerning the treatment of the children. I will be bound by those policies. I also understand that my relationship with the Noyes Home as a special program provider or volunteer is subject to termination by the Noyes Home at any time with or without notice. I understand that this is not an application for employment and as such I will not be considered an employee of the organization. I further agree that if selected, that I will be required to sign a binding confidentiality agreement and waiver of liability.

____________________________________________________________________
Signature of Applicant                                                                   Date

References: Please list three persons who have known you for at least two years (not relatives or employers).
Name: Address: Occupation: Phone: E-mail:
Name: Address: Occupation: Phone: E-mail:
Name: Address: Occupation: Phone: E-mail:

To assist us with your placement please provide any pertinent information such as special interests or hobbies that you feel we should know about.

To assist us with your placement, please list any accommodations that you would need as a part of your volunteer, or special program experience at Noyes Home.