Wellspring Family Services Volunteer Application Form

Thank you for your interest in volunteering with Wellspring Family Services! Please complete the form below and if you have any additional questions or need immediate assistance please contact the Volunteer Coordinator, Saidah McKissick at smckissick@wellspringfs.org.

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

* = Required fields

Name

First name:

Last name:

Best way to contact?:

Employer name:

Email

Email address:

Address

Street 1:

Street 2:

City:

State:

* Zip: *

Phone Number

Home phone:

Work phone:

Cell phone:

Volunteer Opportunities of Interest to You

* Opportunities:

Scheduling

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I would like to serve up to:

hours:

How did you hear about this opportunity?

Demographic Information

This information is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Race (Categorized):

Race:

Emergency Contact

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

* Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate dismissal.

I shall respect the privacy of the people we serve and hold in confidence all information obtained in the course of volunteer services, whether that information is obtained directly or indirectly. Therefore, I will not disclose confidences to anyone except:

1. as mandated by law;

2. to prevent a clear and immediate danger to a person or persons;

3. where I am a defendant or witness in a civil, criminal or disciplinary action arising from the contract;

4. if there is a waiver previously obtained in writing, and then such information may be revealed only in accordance with the terms of the waiver.

I shall be responsible for storage or disposal of professional records in ways that maintain confidentiality.

I shall possess a professional attitude which upholds confidentiality toward the people we serve, colleagues, applicants, and any sensitive situations arising within the agency, and will maintain this professional conduct upon termination.

I understand that violation of this confidentiality statement may be grounds for immediate dismissal.

I Agree