VolunTEEN Summer Application Form 2015

Please return this registration form to Tristyn Card at tcard@wakebgc.org or 721 N. Raleigh Blvd, Raleigh NC 27610 by May 1st. VolunTEENs must attend the summer staff training, Saturday, May 16th at the Raleigh Boys Club at 9 am until noon.

Date ________________

Personal Information Full Name _____________________________________________Birth date_________________ Current Address _________________________________________________________________ City _________________________________ State ___________________Zip _______________ Home Phone _(___)____________________________ Mobile Phone _(___)________________ Email Address __________________________________________________________________ Social Security ____________________________________ (required for all background checks)

Have you previously been a member, volunteered, or employed at any Boys & Girls Clubs? Check one ____YES ___NO

If yes, when and where?

______________________________________________________________________________ Current High School _____________________________________________________________ Current Grade in School __________________________________________________________

Graduation or Anticipated Graduation Date

______________________________________________________________________________ Club Information At which Boys & Girls Club would you like to volunteer: ___ Raleigh Girls Club ___ Washington Elementary Boys

& Girls Club

___ ___ ___

Raleigh Boys Club Brentwood Boys & Girls Club Zebulon Boys & Girls Club

___ Wake Forest Boys & Girls Club

Availability: Please mark the session that you would like to volunteer: _____ June 15 – June 26 _____ June 29 – July 10 _____July 13 – July 24

_____ July 27 – August 7

Will you seek academic credit for this experience? ____ Yes ____ No If seeking academic credit, students are responsible for obtaining and meeting their specific program requirements. Boys & Girls Clubs will provide necessary documentation for credit upon request. Availability Please list days and times that you are available

Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Time available

AdditionaI Information Please circle the applicable response:

Please use a separate sheet of paper to explain any “Yes” responses.

Attachments Please submit the following materials as part of your application package

Personal Statement: Please write a short statement addressing your post high school academic goals. Please keep the statements between one half or one page. ‐

UNDERSTANDING AND AUTHORIZATION I certify that all the answers on the application and any attachments are true and complete to the best of my

knowledge. I also certify that I have not withheld any pertinent information. I agree that in the course of considering my application, you may inquire to verify information considering my background. I specifically authorize you to investigate all statements in the application. I authorize educational institutions, employers and references listed above to give you any and all information concerning my education, employment and fitness to work with children and young people. I further agree to release and hold harmless the Boys & Girls Clubs, institutions, references listed above and any law enforcement agencies from all liability and any damage that may result from furnishing this information to you. Applicant’s Signature: _________________________________________________________________________ Guardian’s Signature: _________________________________________________________________________

Date: ___________________ Emergency Information Emergency Contact’s Name _________________________________ Relationship _________________________ Phone (___ ) __________________________________ Alternate Phone ( ___ ) ___________________________ Hospital Insurance Information Cardholder Name ________________________________ Cardholder ID ________________________________

Do you currently use illegal drugs?

Yes No

Have you ever been convicted of a criminal offense? Have you ever been convicted of child abuse or neglect or is there a pending criminal charge against you for child abuse

Yes No

or neglect?

Yes No

Has your driver’s license been suspended or revoked? Are there any other facts or circumstances involving you or your background that would call into questions your being entrusted with the supervision, guidance and care of

Yes No

young people? Yes No

Please list any allergies, relevant medical history, medical conditions, or pertinent medications: ___________________________________________________________________________________________ Food Restrictions: ____________________________________________________________________________ Medical Release: I accept responsibility in the unlikely event that an accident might take place. I hereby certify that I carry Health and/or Accident Insurance for my child and that I am solely responsibly for the cost or health care for my child; even as a result of my child’s participation in Club programs or activities. I further certify that my child is covered by medical insurance as listed on the above emergency information form. I understand that I am solely responsible to provide such coverage. I understand that I am solely responsible for any consequences of my failure to provide adequate insurance coverage. I agree to abide by all rules of the Boys & Girls Clubs pertaining to health and safety of the members and to inform the Club immediately of any change in my child’s health, health care insurance, or medical provider. I also give permission to Boys & Girls Clubs to seek immediate necessary treatment for my child if necessary. ______________________________________________ _____________________________________________ Guardian’s Signature Volunteers’ Personal Property Neither the Boys & Girls Clubs, Staff or Volunteers shall be responsible for the loss of, or damage to personal property of the participant. We urge participant to not bring radios, video games, or other expensive items to camp to prevent loss or theft. Boys & Girls Clubs, Staff, and Volunteers will not be responsible for lost or stolen items. Property Damage I will be responsible for, and pay, for damage done by my child. Voice and Likeness Release: I understand that the VolunTEEN summer program is an outreach project created by Boys & Girls Clubs, By this release, I consent to the use of _my child’s likeness and voice, including all photographs, video, internet use, and sound recording for educational or promotional purposes by Boys & Girls Clubs, or anyone authorized by these organizations. I acknowledge that Boys & Girls Clubs are the sole owners of all rights to such material on my child’s participation. I understand that I shall receive no compensation for my child’s appearance and participation in this project. If the participant is a minor child, I represent that I am the parent/guardian and I hereby consent to the foregoing on his/her behalf. ____________________________________________________________________ ______________________ Guardian’s Signature Date