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1
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Volunteer Application
SAFE, INC.
Name
*
First
Last
Phone
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer
*
E-mail Address
*
Are you employed?
*
Full Time
Part Time
Student
Areas of Interest
*
Domestic Violence
Sexual Assault
Child Services
Marketing
Are you a victim or survivor of?
Domestic Violence
Sexual Abuse
Sexual Assault
Other
Times available to volunteer?
*
Night
Day
Weekends
Why are you interested in volunteering at SAFE?
*
Emergency Contact
Name
*
First
Last
Relationship
*
Home/ Cell Phone
*
Work Phone
Please list three personal references with addresses & phone numbers:
*
Have you had any of the following:
*
Prior abuse or molestation allegations
Incidents, convictions, or pleading of guilty or "no contest" to misdemeanors
Incidents, convictions, or pleadings of guilty, or "no contest" to felonies
None of the above
Please explain any yes answers from the previous question.
Agree by checking the boxes.
*
I understand that SAFE, Inc. will conduct a mandatory background check prior to my being admitted to the volunteer program. I agree to hold harmless SAFE, Inc. and any reference(s) provided by me should I not be in agreement with the reference(s).
I pledge to keep the location of the SAFE, shelter and the names of the clients confidential. I will respect and maintain confidentiality on all information pertaining to clients who seek help from the program. If I violate this pledge, I will automatically be terminated as a volunteer.
I, __________________, am willing to serve as a volunteer for SAFE, Inc. shelter. I agree to release SAFE, from all liability for any injury or personal damage I might contact the Volunteer Services Coordinator or the Executive Director as soon as possible. If I choose to discontinue my volunteer work with SAFE, Inc., I will submit in writing a two week notice.
I understand that untruthful answers are grounds for dismissal or refusal of my Volunteer application.
Signature
*
First
Last
Date
*
MM slash DD slash YYYY
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