03-ALL-ALL-0040 FOR OFFICE USE ONLY Revised 8/06 TYPE ______________ ACCESS # _________________ START __________­­­­­­___­­­­ SITE _________________ SCHEDULE _____________ POSITION _________________ ORIENTATION _____________ SUPERVISOR _________________ BCII ______________ DATES _________________ LEVEL _____________ WOOD LANE VOLUNTEER APPLICATION FORM Thank you for your interest in serving as a volunteer with Wood Lane. Please complete this volunteer application form in its entirety. (Wood Lane staff complete Sections I, II, VIII and IX). The information you provide will be considered confidential. SECTION I Name:_____________________________________ Social Security #:________________ Date:_______________________ Address/Apt #:_____________________________________________ _____________________________________________ City:______________________________________________State:____________________ Zip________________________ Telephone (home):_______________________ (cell):_______________________ Email:___________________________________ Birth date:______________________________ SECTION II Placement preferences (if known): ___________________________________________ _________________________________ Use boxes below to indicate specific times during the morning, afternoon and evening for each day that you are available Sun. Mon. Tues. Wed. Thurs. Fri. Sat. | | | | | | | Morning | | | | | | | | | | | | | | | | | | | | | Afternoon| | | | | | | | | | | | | | | | | | | | | Evening | | | | | | | | | | | | | | Available (circle all that apply): Fall Winter Spring Summer List your interests, activities and special skills: _______________________________________________________________________________ __________________________ Do you have a car? Yes No SECTION III Applicant currently is or has: been convicted of a traffic violation Yes No been convicted of a felony: Yes No been a litigant in a lawsuit Yes No physical conditions which would impact placement: Yes No Please explain “Yes” responses:_______________________________________________ SECTION IV for public school students (give school and year only) or university students fulfilling course requirements: School:___________________________________ Major:____________________________ Year in school__________ Course Name/Number:_______________________ Instructor_________________________ Number of hours required _________ Course Name/Number:_______________________ Instructor_________________________ Number of hours required _________ SECTION V Volunteer experience or employment relating to volunteer placement with Wood Lane Site Dates Position held | | | | | | to | | | | | | | | | | | | to | | | | | | | | | | | | to | | | | | | SECTION VI Education (Circle Year Completed): Grade: 7 8 9 10 11 12 College: 1 2 3 4 Grad Major:______________________ SECTION VII References (to be completed by volunteers requesting placement as a community friend or other level IV volunteer placement) 1. Employer, teacher, minister or other professional: Name:___________________________________________________ Relationship:________________________________ Address/City/State/Zip_______________________________________________________ _________________________ Phone:__________________________________________________ 2. Personal reference: Name:___________________________________________________ Relationship:________________________________ Address/City/State/Zip_______________________________________________________ _________________________ Phone:__________________________________________________ SECTION VIII In case of an emergency, notify: Name:___________________________________________________ Relationship:________________________________ Address/City/State/Zip_______________________________________________________ _________________________ Phones numbers of emergency contact : home___________________ work _______________ cell ___________________ Do you have any comments or questions?_______________________________________ ______________________________________________________________________________ SECTION IX I certify that the facts in this application are true and accurate to the best of my knowledge and I authorize investigation of all statements contained herein and contact with the references listed above to provide Wood Lane with all appropriate information. I understand I may be transported in Wood County Board of MR/DD-owned vehicles to and from activities in the course of my volunteer work. I also understand it is my responsibility to inform the Volunteer Coordinator of any changes in information which I have provided on this application. Wood Lane __ may __ may not use my name during National Volunteer Week for recognition purposes. ___________________________________________________ ______________________ Signature Date ___________________________________________________ ______________________ If minor, parent/guardian’s signature Date RETURN TO: Volunteer Coordinator Wood Lane, 11160 E. Gypsy Lane Road, Bowling Green, Ohio 43402