volunteer application -...
TRANSCRIPT
Volunteer Application
Mail or return to 1020 Fox Ave, Apt. 504,
Lewisville, TX, 75067 OR e-mail to
Name: _________________________________________________________
Occupation: DOB: _______________
Address: City/State/Zip: ________________________________
Home Phone: Mobile Phone: _______________
Email:
I prefer to be contacted by phone □ email □ text □
If you are applying as a family, please list children, ages, and grade in school
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If you are applying for a small group, please list names, emails and phone numbers of others in
your group who plan to visit the families. Each adult in the group who will be visiting the
families must fill out permission to run a background check.
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Name: Phone: ____________________________
City: Membership status: _____________________
Name:
City:
Phone:
Personal Information
Church Information
Family Information
Work Information
Small Group Information
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Have you worked with refugees or people from third world countries before? If so, please describe your experience.
Why do you want to serve refugees through Chin Community Ministry?
Indicate any skills, professions, or hobbies you believe may be beneficial to refugee assistance.
Please share briefly about your walk with Jesus Christ. (ie: when were you saved, what do you
do to grow in & live out your faith, etc.)
What are your spiritual gifts?
In which of the following ministry areas are you interested in volunteering?
□Donations (clothing, furniture, or household goods) □ Data Entry
□ Family Mentoring or School Buddies □ Summer Reading Program
□ Fundraising Team □ Health Day □ Share Day
□ First Christmas in the United States □ Soccer (coach, helper, transportation to games, snack
provider, etc)
□ Publicity □ Communications Team
□ Other
If you will be volunteering on a weekly basis, what days would you be available?
□ Mon □ Tues □ Wed □ Thur □Fri □ Sat
Please list two references who are not relatives.
Name:
Phone:
Relationship:
Email:
Name: Relationship: _______________________
Phone: Email:
Volunteer Information
References
Availability
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Please initial the following statements and then sign where indicated. For those under the age of 18 who are participating, a parent must sign a Parental Consent Form.
____ I certify that the statements made above in the application are true and correct. ____ I have read the Mission Statement of Chin Community Ministry (located on the website www.lewisvillechin.org). I understand it and desire to work with CCM to carry out the goals of the mission statement. ____ I understand that CCM serves the Chin people with permission of the local Chin pastors. Since the Chin in Lewisville are almost all from a Baptist or Pentecostal background, I will respect their denominational beliefs rather than trying to change them. (However, mutual discipleship, i.e. learning from each other how to grow in maturity in our faith, is encouraged) ____ I understand that neither CCM nor its affiliated churches provide insurance coverage for losses, sicknesses, or injuries that may occur while participating in a CCM program. I am responsible for providing my own insurance coverage. ____ In the event of medical emergency, I hereby consent to the necessary and proper treatment, surgery, and and/or anesthesia by a licensed physical or health care professional for the individual named on this form. ____ By signing this form, I agree and understand that I will be operating as a volunteer for CCM. I do not expect remuneration for my services. I understand that I may be reimbursed for incidental expenses but must receive prior approval for reimbursement from CCM staff. ____ I am aware of the potential risks to me and my property during my volunteer assignment with CCM. With such knowledge, I voluntarily release and indemnify CCM, their representatives andvolunteers from any and all liability related to the activities of the ministry.____ I do hereby give CCM the right to use my name (or a fictional name), picture, portrait orphotograph of me in any lawful manner.____ I understand that to be an active member of CCM, CCM must have a cleared criminalbackground check on me.____ I understand that to be an active member of CCM, I may be required to attend a volunteertraining session._____ I understand that confidentiality is a key aspect of my volunteer assignment. Aside from CCMleadership, I agree to keep all personal matters of CCM’s clients confidential.____ I agree to provide CCM proof of current and valid driver’s license and auto insurance (if over18). (please include this with your application)
Signature: _________________________________________________________ Date: ________________________________
Printed Name: _____________________________________________________
Release Form
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CONFIDENTIAL
CCM Background Check Authorization
Print Name: (First) (Middle) (Last)
Former Name(s) and Dates Used:
Current Address Since: (Mo/Yr) (Street) (City) (Zip/State)
Previous Address From: (Mo/Yr) (Street) (City) (Zip/State)
PPrevious Address From: (Mo/Yr) (Street) (City) (Zip/State)
Social Security Number: DOB:
Telephone Number:
Drivers License Number/State:
Email address:
The information contained in this application is correct to the best of my knowledge. I hereby authorize Chin Community Ministry and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Chin Community Ministry or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.
**Chin Community Ministry and its designated agents and representatives shall maintain all
information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Signature: ______________________________________ Date: ______________
Form Revised: 04/14/17
Volunteer Parental Consent Form
Chin Community Ministry requires parental consent for any young person ages 17 and under who is participating in any voluntary activities. Please complete the form below and sign to give your consent to the activities detailed. All information given in this form is confidential. Volunteer’s Personal Details:
Name of Participant:
Home Address:
Date of Birth:
Phone Number:
This section is to be completed by parent / guardian:
I give permission for my son / daughter to volunteer for Chin Community Ministry program. I stipulate that my son or daughter has not been arrested and is of good moral character, posing no threat to the
Chin children.
I understand that the Chin are a Christian people group, and that Chin Community Ministry is faith-based.
I understand that use of alcohol, drugs or profanity while working with the Chin students is prohibited. I release Chin Community Ministry from and against any and all liability for any harm, injury, damage, claims,
costs and expenses of any nature that may accrue to my child arising out of my child’s volunteer activities.
Signed:
Print Name:
Date:
Relationship to Child:
Emergency Phone Number:
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