Today's Date:
| Birthdate (mm/dd/yyyy):*
| SSN:
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Full Name:*
| Race/Ethnicity:*
| Sex:*
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E-mail:
| Phone (W):
| Phone (H):
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Current Address:
| Mobile/Pager:
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Emergency Contact Name:
| Relationship:
| Emergency Contact Phone:
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Occupation
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Major:
| | Employer:
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Level:
| | Position:
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Expected Graduation Date:
| | Work Address:
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Permanent Phone:
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Permanent Address:
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Volunteer Preferences
For which program(s) would you like to volunteer?
Note: volunteer restrictions apply to items marked with an asterisk | | |
Cabrini Green
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Washington Park
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Uptown
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Additional Information
How did you hear about us? | | |
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Returning Volunteers
If you are a returning volunteer, please answer the following three questions and skip the next section. | | |
When did you begin volunteering with Chicago Youth Programs? (mm/yy)
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I am interested in being a Volunteer Program Coordinator:
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If you have volunteered before, would you like to tutor/mentor the same child?
| | If so, what is the child's name?
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New Volunteer Information
If you are a new volunteer, please complete the following questions, otherwise continue on to the Background Information section.
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Why do you want to volunteer with Chicago Youth Programs? What do you expect to gain from your experience as a volunteer?
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What other activities are you involved in?
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Do you have any special skills or interests you feel might benefit the children of this program?
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Do you have any volunteer and/or paid experience or formal training working with children and youth (i.e. tutoring, teaching, camp counseling, training dates/classes, etc.)? Please explain.
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Do you have an age or gender preference for the child with whom you will work?
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Background Information
Please answer the following questions openly and honestly. Answering "Yes" for any of the following questions does not necessarily bar you from volunteering with Chicago Youth Programs.
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Have you ever been convicted of a felony?
| If yes, please explain:
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Have you ever been convicted of a crime involving children, including sexual abuse/molestation, physical abuse, or neglect and/or are you the subject of an indicated child abuse and maltreatment report on file in any state?
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Have you ever been terminated, suspended, placed on probation, reprimanded, or otherwise penalized by an employer for child abuse and/or maltreatment in this state or elsewhere?
| If yes, please explain:
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Volunteer Agreement
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| I declare that this Volunteer Application is true and complete to the best of my knowledge. | | |
Please type name:
| Date:
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I agree that I will not use any information obtained from the children as a volunteer with Chicago Youth Programs, Inc! for personal gain or profit. | | |
Please type name:
| Date:
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I authorize Chicago Youth Programs, Inc! to conduct a criminal background check on me through Illinois State Police in order to insure utmost safety for the children and families of Chicago Youth Programs. | | |
Please type name:
| Date:
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I understand as a volunteer with Chicago Youth Programs, Inc! that the nature of volunteer activities may involve physical activity, contact with unfamiliar people, travel to and from unspecified locations, and other potential risks of injury. Knowing this, I still wish to volunteer and hereby assume the risk for any accident or injury, to person or property, which I may sustain in conjunction with my participation as a Chicago Youth Programs, Inc. volunteer or in any Chicago Youth Programs, Inc! activity. In addition, I hereby release and discharge Chicago Youth Programs, Inc! and any of its directors, officers, employees, affiliates, or successors from any and all liability and responsibility for any such action or injury.
I understand that I am required by law to report any suspicion of child abuse to the Program Director or, in case of the Program Director's absense, the Chief Administrative Officer. | | |
Please type name:
| Date:
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