Advocates for Victims of Abuse
VOLUNTEER APPLI CATION
Please Print
_________________________ ___________________ __
Date Last Name First Name Middle Initial
Residence Address
____________________ _______________ ___ _____-____
No. & Street City State Zip
(___) ________ (___) ________ (___) ________ ______________
Home Phone Mobile Phone Work Phone Email Address
Volunteer Opportunities Desired
Community Advocate .....................................................................
Child and Family Advocate.............................................................
After School Program (tutoring, mentoring) ....................................
Special Events Planning.................................................................
Support Group Facilitator ...............................................................
Administrative Assistance ..............................................................
Community Outreach .....................................................................
Self-Defense Instructor/Assistance.................................................
What days and hours are you available for work? Fill in grid below:
Monday Tuesday Wednesday
Thursday
Friday Saturday
Sunday
Morning
Afternoon
Evenings
Overnight
Personal Information
How did you hear about AVA ?
____________________________________________________________
Why do you want to volunteer at AVA ?
____________________________________________________________
____________________________________________________________
What are your interests?
____________________________________________________________
____________________________________________________________
What is your volunteer experience?
____________________________________________________________
____________________________________________________________
What strengths can you bring to AVA?
____________________________________________________________
____________________________________________________________
Did any of your volunteer positions involve working with children? Yes No
If yes, explain:______________________________________________________
_______________________________________________________________________________
Were you ever discharged or asked to leave your volunteer position? Yes No
If yes, explain:____________________________________________________
__________________________________________________________
If selected, would you have a reliable means of transportation to and from your volunteer opportunity?
Yes No
Some volunteer opportunities at AVA involve dealing with victims of trauma. Is there any reason you
believe you would not be able to volunteer for AVA in this capacity? Yes No If so,
please explain:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever been convicted of a criminal offense (Conviction of a crime will not necessarily
constitute an ..................................................................................
absolute bar to employment).......................................................... Yes No
If yes, state nature of the crime(s), when and where convicted and disposition of the case.
____________________________________________________________
____________________________________________________________
(Note: Consideration for employment may include the nature of any criminal offense conviction, the
date of the offense(s), the surrounding circumstances and the relevance of the offense to the
position(s) applied for.)
Are you currently out on bail or on your own recognizance pending trial for a prior arrest? Yes
No
If yes, state nature of the crime(s), when and where arrested and the status of the case.
____________________________________________________________
____________________________________________________________
Have you ever been convicted of crimes against children? Yes No
If yes, please give details: ____________________________________________________________
Have you had personal experience involving child welfare, foster care, adoption, or
juvenile services? Yes No
If yes, please explain: _______________________________________________________________
Have you ever been involved in an investigation by Humboldt County Dept. of Social
Services or any other child welfare agency? Yes No
If yes, please explain:
________________________________________________________________
Do you currently have any involvement with Family or Juvenile Court? Yes No
If yes, please explain: _______________________________________________________________
Have you ever had a Temporary Restraining Order (TPO) against you?
Yes No
If yes, Dates:_________________________________________________________
(Note: Consideration for employment may include the nature of the pending criminal offense(s), the
date(s), the surrounding circumstances and the relevance to the position(s) applied for.)
Employment Status
Are you currently employed?.......................................................... Yes No
If yes, where are you currently employed? ___________________________________________
Education Completed
High School
College (Degree completed:____________ )
Other
________________________
GED
Graduate (Degree completed:____________ )
Other Skills
Do you speak a secondary Language? Yes No
Spanish French German Other
Write Speak Read
Do you have any other experience, training, qualifications or skills which you feel make you especially
suited for volunteering at AVA ? Yes No.......................... If so, please explain:
____________________________________________________________
____________________________________________________________
____________________________________________________________
References
Please list three (3) character references that have known you for at least two (2) years and Not
related to you. You may include employer, if you have been employed for at least one (1) year.
Complete addresses are REQUIRED. Thank you
1) Name: ____________________________ Phone # ______________Cell # _____________
Address: ___________________________ City ________________ State ___ Zip ________
How do you know this person?___________________________________________________
How long have you known this person? ___________________________________________
2) Name: ___________________________ Phone # ______________Cell # ______________
Address: ___________________________ City ________________ State ____ Zip _______
How do you know this person?___________________________________________________
How long have you known this person? ____________________________________________
3) Name: ____________________________ Phone # ______________Cell # _____________
Address: ___________________________ City ________________ State ___ Zip ________
How do you know this person?____________________________________________________
How long have you known this person? ____________________________________________
Referred by: Flier Friend Internet Newspaper Local radio National media
Volunteer referral agency Facebook Other: ____________
Please Read Carefully, Initial Each Paragraph and Sign Below
______ I hereby certify that I have not knowingly withheld any information that might adversely affect
my
Initials chances for volunteering and that the answers given by me are true and correct to the best of
my knowledge. I further certify that I, the undersigned applicant, have personally completed
this application. I understand that any omission or misstatement of material fact on this
application or on any document used to secure a volunteer position shall be grounds for
rejection of this application or for immediate discharge if I have been selected to volunteer,
regardless of the time elapsed before discovery.
______
Initials I hereby authorize AVA to thoroughly investigate my references, work record, education,
criminal record, and other matters related to my suitability for a volunteer position In addition,
I hereby release AVA, my former employers, and all other persons, corporations,
partnerships, and associations from any and all claims, demands, or liabilities arising out of
or in any way related to such investigation or disclosure.
______ I understand that nothing contained in the application, or conveyed during any interview
which may
Initials be granted or, if hired, during my volunteer experience at AVA, is intended to create a
volunteer contract between AVA and me. In addition, I understand and agree that if I am
selected as a volunteer, my volunteer tenure is for no definite or determinable period and
may be terminated at any time, with or without prior notice, at the option of either myself or
AVA, and that no promises or representations contrary to the foregoing are binding on me or
AVA unless made in writing and signed by me and the AVA designated representative.
______ Should a search of public records (including records documenting an arrest, indictment,
conviction,
Initials civil judicial action, tax lien or outstanding judgment) be conducted or obtained by AVA, I
may be entitled by law to copies of any such public records obtained by AVA unless I mark
the check box below. If I am not hired as a result of such information, I may be entitled to a
copy of any such records even though I have checked the box below.
____ I further understand all information received as a result of the AVA office inquiries Initials
will be held in strict confidence, and any information received by the program in this
regard shall not be released to the applicant.
_____ I understand that my records are protected under the Federal Confidentiality
Initials Regulations and cannot be disclosed without my written consent unless otherwise
provided for in the regulations. I also understand that I may revoke this consent at any time
except to the extent that action has been taken in reliance on it and that in any event this
consent shall automatically expire upon my termination of involvement with the AVA
organization.
I waive receipt of a copy of any public record described in the paragraph above.
PURSUANT TO FEDERAL CODES, DISCLOSURE OF CLIENT INFORMATION IN A MANNER
NOT AUTHORIZED BY 42 CFR PART 2 IS A FEDERAL CRIMINAL OFFENSE PUNISHABLE BY
A FINE OF NOT MORE THAN $500.00 IN THE CASE OF A FIRST OFFENSE AND NOT MORE
THAN $5,000 IN THE CASE OF EACH SUBSEQUENT OFFENSE.
I HEREBY SUBMIT APPLICATION TO BE CONSIDERED AS A CASA VOLUNTEER AND
ATTEST THAT ALL THE INFORMATION HEREIN IS TRUE AND CORRECT.
__/__/__ ____________________________________________________________________
Date Applicant’s Signature
Authorization for the Release of Information
I, ______________________________ , hereby certify all statements made on this application are
true and correct to the best of my knowledge. I understand by submitting this application I authorize
inquiries to be made concerning my suitability as a volunteer. The information requested in this
application and any information that may be obtained by AVA through inquiry of
others, will be used only for the purpose of determining suitability as an AVA volunteer.
I further understand all information received as a result of the AVA office inquiries will be held in
strict confidence, and any information received by the program in this regard shall not be released to
the applicant.
I understand that my records are protected under the Federal Confidentiality Regulations and cannot
be disclosed without my written consent unless otherwise provided for in the regulations. I also
understand that I may revoke this consent at any time except to the extent that action has been
taken in reliance on it and that in any event this consent shall automatically expire upon my
termination of involvement in the Advocates for Victims of Abuse organization.
PURSUANT TO FEDERAL CODES, DISCLOSURE OF CLIENT INFORMATION IN A MANNER
NOT AUTHORIZED BY 42 CFR PART 2 IS A FEDERAL CRIMINAL OFFENSE PUNISHABLE BY
A FINE OF NOT MORE THAN $500.00 IN THE CASE OF A FIRST OFFENSE AND NOT MORE
THAN $5,000 IN THE CASE OF EACH SUBSEQUENT OFFENSE.
Signature Date
AVA authorized representative signature Date
Confidentiality Code
PURSUANT TO FEDERAL CODES, DISCLOSURE OF CLIENT INFORMATION IN A MANNER
NOT AUTHORIZED BY 42 CFR PART 2 IS A FEDERAL CRIMINAL OFFENSE PUNISHABLE BY
A FINE OF NOT MORE THAN $500.00 IN THE CASE OF A FIRST OFFENSE AND NOT MORE
THAN $5,000 IN THE CASE OF EACH SUBSEQUENT OFFENSE.
We cannot emphasize strongly enough your responsibility to maintain strict confidentiality in your role
as a volunteer. Any information to records pertaining to your case and the people involved in the
case, is strictly confidential. It may be discussed with Court personnel or others involved in an official
capacity that are authorized to receive such information. The families that come before the Court
have a legal right to their privacy. Violation of confidentiality can result in legal ramifications for the
violator, increased pressures on families and possibly increased risk to already vulnerable children.
The other agencies and persons with whom you may be in contact – police, schools, welfare, mental
health, physicians, etc., - are also bound by strict confidentiality laws. The only reason that they can
share their information candidly with you is that they have been given assurances that you will
respect the confidentiality and privacy of these families the same as they do.
I, ______________________________ , hereby certify that I recognize that disclosure of client
information is a FEDERAL CRIMINAL OFFENSE and hereby agree that anything I read, hear or see
in or resulting from a family court proceeding will remain confidential.
I, swear and say that I am making the above statement herein; that I have read the
statement affirmations set forth in the above and foregoing statement and know the contents thereof
and the same is true to my knowledge.
Signature Date
AVA authorized representative signature Date
Declaration of Required Minimum Insurance Coverage
DATE AND SIGN THE DECLARATION THAT REPRESENTS YOUR STATUS
I, ______________________________ , hereby affirm and represent that I have automotive collision
and liability insurance coverage with ______________________________ in the amount of a
minimum of $100,000/$300,000. I will maintain this level of automobile insurance coverage
throughout my participation with the Advocates for Victims of Abuse organization.
Signature Date
AVA authorized representative signature Date
I, ______________________________, hereby affirm and represent that I can not maintain the
minimum coverage of $100, 000/$300.000 liability insurance. I understand that I cannot drive any of the
AVA children around. I further understand that it is only after I obtain and maintain this coverage that I
will be permitted to drive an AVA child in my car.
Signature Date
AVA authorized representative signature Date
Authorization to Release Information
I hereby authorize the AVA organization to conduct an investigation of my background
and to gather any and all information which may reflect on my suitability as a volunteer. I
agree to hold the AVA organization harmless from any and all liability resulting from such investigation.
I understand that all information received by AVA as a result of their investigation of me will be held
in strict confidence, and shall not be released by AVA to me.
Last name ___________________ First name ______________ Middle ___________
__________________________________________________________________________________
Aka’s (Maiden Name. Nickname, Previous Marriages, Other changes)
Home address _________________________________________________ Apt. # ____________
City ____________________________ State _______________________ ZIP _____________
Place of Birth ___________________ Date of Birth _________________ SS# _______________
__________________________________________________________________________________
Race Sex Height Weight Hair Color Eye Color
(This information is for computer search only)
________________________________________________________________________________________________________________________
Driver’s License# State Exp. Date
Access to car?
Yes
No
Liability Insurance Co./Amount of Coverage _____________________
______________________________ _________________________________
Signature Date
Any applicant found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sex offense, child abuse or neglect,
or related acts that would pose risks to children or the AVA organization and CASA program’s credibility is not eligible to be An AVA Volunteer. Any applicant
that is found to have committed a misdemeanor or felony that is unrelated to or would not pose a risk to children and would not negatively impact the
credibility of the
AVA organization, the organization will consider the extent of the rehabilitation since the misdemeanor or felony was committed as well as other factors
that may influence the decision to accept the applicant.
The Advocates for Victims of Abuse organization is an equal opportunity employer. AVA does not discriminate on the basis of race, color, creed, religious
preference, gender, disability, sexual preference, or veteran status; unfortunately, not every applicant is accepted for our volunteer positions. AVA
reserves the right to deny a volunteer position to any applicant without explanation. If a volunteer applicant refuses to sign a release of information
form or submit to fingerprinting for any of the checks required the AVA organization will reject their application.