Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Birthplace (City & State)
*
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone (home or cell)
*
(###)
###
####
Work Phone
(###)
###
####
Driver's License: State & DL#
*
Do you have transportation?
*
Marital Status
*
Spouse Name
First Name
Last Name
Spouse Phone
(###)
###
####
Children Names & Ages
Employer
Position
Supervisor
Can we contact you at work?
Level of Education
*
If student, full or part time?
Degree or Major:
Graduate when?
Are you bilingual?
*
If YES above, list language(s) and fluency:
Formal training or experience related to our work:
List other volunteer experience:
Special skills:
(i.e., computer, fundraising, public relations, etc.)
Do you have experience working with victims?
*
If YES above, explain:
(i.e., type of activity, ages of victims, professional or volunteer)
Have you ever applied to another agency that works with victims?
*
If YES above, explain:
List name of agency(ies), whether you were accepted. and your responsibilities.
Why do you want to be a SALonDV volunteer?
*
Do you have personal or professional experience with the following:
Check all that apply.
If YES above, explain below:
Describe your experience with anything you checked in the question above.
Have you ever been convicted if a criminal offense?
*
Please, exclude the following situations: (A) Minor traffic violation for which the fine was $200.00 or less; (B) any offense finally settled in Juvenile Court.
If YES above, please explain:
(dates, county, disposition)
Will your volunteer service be a part of court ordered community service?
*
If YES above, explain below:
List the following: (1) # hours required to serve; (2) date to be completed; (3) name of probation officer or court contact AND phone number
Have you ever been or are you currently on parole?
*
Any DWI/DUI arrests or convictions?
*
Have you ever had your driver’s license suspended or revoked?
*
Do you know or ever had treatment for chemical or alcohol dependency?
*
Have you ever or do you now engage in sexual misconduct that, if known, could cause harm to a client, or SALonDV?
*
Have you ever been charged or convicted of sexual misconduct (including pornography)?
*
If YES to any of the above, explain below:
Reference #1
*
List name, how you know them, how long you have known them, and phone number.
Reference #2
*
List name, how you know them, how long you have known them, and phone number.
Reference #3
*
List name, how you know them, how long you have known them, and phone number.
Please check the ways in which you may be interested in volunteering:
Other skills or interests:
What day(s) and time(s) might you be available to volunteer?
Date of Application
*
MM
DD
YYYY
