Volunteer Application - CAASTLC, Inc. - Services Toward Empowering People,Inc.

Volunteer Application
PERSONAL INFORMATION
Date:
Name:
Address:
City:	State: Zip:
Phone Number:
Social Security#:
Email:
Current School or Place of Work:
Occupation (title and organization):
Work Address:
Work phone:
Work Hours:

ASSIGNMENT REQUEST:

Volunteer position(s) applied for or type of volunteer work desired:

Type of assignment: Volunteer Internship Practicum

Date you are available to start assignment:

Are you required to complete a certain number of hours ?

YES NO

Number of hours you are required to complete:

Projected date of completion of assigned hours:

Have you ever previously volunteered for CAASTLC, Inc., STEP, Inc. or Metroplex, Inc.?

YES NO

Do you have any handicap or limitations that need to be accommodated for?

YES NO

If yes, please describe:

Have you ever been convicted of a crime?

YES NO

If yes, please explain (a conviction will not automatically bar your participation as a volunteer, intern, or practicum student.):

Can you submit legal proof of identity?

YES NO

Transportation:(How you will get to your assignment)

Public Trans Walk Taxi/Car Svc Car

If by car, do you possess a valid Driver's license?

YES NO

Issuing state:

Do you have current automobile insurance?

YES NO

If you have been assigned to do court ordered community service please give contact information for your P.O.

Name:
Phone#:

If you are an internship or practicum student please give contact information for your school department head or administrator to whom you will report your hours of completed work.

Name:
Phone#:

If you are an independent volunteer, how were you referred to us?

Volunteer/Relevant Experience

1.	Organization:
	Address
	Phone #
	Person you reported to:
	From: to
	Duties:

2.	Organization:
	Address
	Phone #
	Person you reported to:
	From: to
	Duties:

3.	Organization:
	Address
	Phone #
	Person you reported to:
	From: to
	Duties:

4.	Organization:
	Address
	Phone #
	Person you reported to:
	From: to
	Duties:

REFERENCES List three (3) references (do not include relatives or employers).
Name:
Address:
City:
State:
Zip:
Telephone:

Name:
Address:
City:
State:
Zip:
Telephone:

Name:
Address:
City:
State:
Zip:
Telephone:

EMERGENCY RECORD In case of emergency notify:
Name:
Relation:
Address:
City:
State:
Zip:
Telephone:

I hereby authorize CAASTLC, Inc. to contact, obtain and verify the accuracy of the information contained in this application from all sources. I also hereby release from liability CAASTLC, Inc. and its representatives for seeking, gathering and using information to make assignment decisions and all persons or organizations for providing such information.

If I am assigned as a volunteer, intern, or practicum student, I acknowledge that there is no specific length of assignment and that either I or CAASTLC, Inc. can terminate this assignment at any time for any reason. I understand that this application is only for requesting assignment at CAASTLC, Inc. as a volunteer, intern, or practicum student.

I understand that it is the policy of this organization not to refuse or otherwise discriminate against a qualified individual with a disability because of that person's need for reasonable accommodation as required by the ADA.

I understand that if I am accepted as a volunteer, intern, or practicum student, I will be required to provide satisfactory proof of identity. I represent and warrant that I have read and fully understand the foregoing.

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After you submit this form you will be taken to a page where you
can upload your resumé to us for review.

CAASTLC, Inc. disclaims any warranties regarding the accuracy
or completeness of any information appearing on this website.