Volunteer Application I. Identifying Information:Full Name:Address:City:State:Zip:Home Phone:Cell Phone:Work Phone:Email Address: Driver’s license # and expiration:Gender:MaleFemaleVeteran statusYesNoDate of Birth: Race:American Indian/Alaskan NativeAsianBlack/AfricanHispanic/ LatinoNative Hawaiian/Pacific IslanderWhiteOther Race:For Civil Rights Compliance Plan reporting, please fill in the gender, date of birth and race sections on this form. How did you hear about Circles of Support:Community in which you wish to volunteer: Fox Valley Green Bay Oshkosh II. Educational and Employment History:EducationHigh School:Did You Graduate?NoYesCollege/Tech school:Did You Graduate?NoYesIf yes, please include your degree along with major/minor earned:College & Advanced degree(s):List any certificates, trade licenses, computer skills or other special skills:EmploymentMay we contact your current employer?NoYesPrevious employer?NoYes1. Current Employer:Phone:Address:Date from: Date to: Position:Supervisor:What hours do you work:2. Previous Employer:Phone:Address:Date from: Date to: Position:Supervisor:III. Other Experiences:Volunteer Experience/Organizations participated with:Reason you have chosen Circles to volunteer with:IV. Background Check Information:I give permission for Goodwill NCW to perform a criminal background check on me, including local, state and federal records.YesNoI have criminal convictions or pending charges.YesNoIf yes, please explain:Are you currently on court or correctional supervision?YesNoPlease list any alias, maiden name, and/or former married name:V. ReferencesList two persons who are not related to you, you have known at least one year and who are willing to give a work-related reference on your current or past work performance. Please fill in complete email address as letters will be emailed to each person.1) Full Name:Relationship:Years Acquainted:City:State:Phone:Email: 2) Full Name:Relationship:Years Acquainted:City:State:Phone:Email: VI. Personal Information:Do you have any circumstances in general which might affect the quality or frequency of your volunteering?YesNoIf yes, please explain:Are you currently working any program of recovery?YesNoIf yes, please explain:Answering yes to the above questions is not an automatic disqualification. As an agency committed to preserving the integrity of the Circles Program, these areas must be explored and are not intended to offend or invade the privacy of the applicant. My signature hereby certifies that all of the above statements are true to the best of my knowledge. I understand that any misrepresentation may justify my dismissal from the Circles of Support. I understand and agree that any and all knowledge or information obtained in the course of my work with the Circles of Support, with respect to the conduct and details of the participant and other volunteers will be forever held inviolate and that I will not impart the knowledge acquired outside of Circles policy. I understand that I personally assume all responsibility for the volunteer relationships between myself and the other Circles members and participants. I agree to hold the Circle of Support, the Department of Corrections, and Goodwill NCW harmless for any actions of a participant, member or myself.CaptchaIn case you should choose to transport someone, and/or to receive mileage compensation, we must also have your certificate of insurance on file. NameThis field is for validation purposes and should be left unchanged.