Name

Email

Address

City

State

Zip

Church

Home Phone

Cell Phone

Employer/Occupation

Phone

Date of Birth (A copy of your drivers license or ID will be required, prior to volunteering.)

Emergency Contact Name

Emergency Contact Phone

Are you volunteering with a group? Are you volunteering with a group? Yes No

What is the group name?

Name of the lead contact for the group

Group Contact Email

Group Contact Phone

I am interested in working with (Check all that apply) I am interested in working with (Check all that apply) Children/Youth Elderly

Volunteer Opportunities (Check all that apply) Volunteer Opportunities (Check all that apply) Preparing/Serving Meals Tutoring/Mentoring Youth Retail Assistance/Stocking Camp Projects/Outdoors Admin/Support Construction/Maintenance

I am available: (Check all that apply) I am available: (Check all that apply) Monday Tuesday Wednesday Thursday Friday Sat Sun

Monday Times Available

Tuesday Times Available

Wednesday Times Available

Thursday Times Available

Friday Times Available

Saturday Times Available

Sunday Times Available

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Have you ever been convicted of any criminal violation of any type of sexual misconduct? Have you ever been convicted of any criminal violation of any type of sexual misconduct? Yes No

Please explain:

Have you ever been convicted of any criminal offense (misdemeanor or felony) in a court of law? Have you ever been convicted of any criminal offense (misdemeanor or felony) in a court of law? Yes No

Please explain:

Have you ever been disciplined, suspended, or terminated by an organization due to allegations of sexual misconduct or abuse? Have you ever been disciplined, suspended, or terminated by an organization due to allegations of sexual misconduct or abuse? Yes No

Please explain:

Name/Title

Phone

Name/Title

Phone

Name/Title

Phone

Are you volunteering to fulfill a Community Service hours requirement? Are you volunteering to fulfill a Community Service hours requirement? Yes No

Please provide the total number of Community Service hours to complete:

What is the reason Community Service hours required?

What was the offense that led to the Community Service hours?

When do the Community Service hours need to be completed? (mm/dd/yyyy)

Please list the name and phone number for your supervisor or probation officer:

Please list the county where the offense/arrest occurred.

Have you volunteered or worked for South Side Mission in the past? Have you volunteered or worked for South Side Mission in the past? Yes No

In what location or ministry area?