Volunteer Application Step 1 of 4 25% Name* First Middle Last Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home or Cell Phone*Work PhoneEmail* How did you hear about our volunteer program?*Which Volunteer Opportunity are you applying for Administrative Volunteer Community Ambassador Mental Health Awareness Month This Is My Brave Champions for Mental Health Are you currently in school?* Yes No If yes - where? What is your current grade level? Are you currently retired?* Yes No If yes - what kind of work did you do? Do you have prior volunteering experience? If so, please list the organization with a brief description of your volunteer duties below.Do you have prior experience with individuals with behavioral health issues? If yes, please briefly describe below.What specific qualifications, certifications, credentials, and academic degrees do you have, if any? Do you have any concerns working around clients?* Yes No Please select your preferred day(s) of the week to volunteer:* Monday Tuesday Wednesday Thursday Friday Please select your preferred time(s) of the day to volunteer:* Morning Afternoon Evening Are you available year round?* Yes No Are you volunteering to fufill a community service requirement?* Yes No If yes, how many hours of service are required? less than 30 hours 30-50 hours 50-100 hours 100-200 hours 200+ hours Have you been convicted of any motor vehicle violations within the past five years?* (e.g. speeding tickets, loss of license, failure to stop, etc)* Yes No If yes, please explain: Have you ever been convicted of a felony or other crime within the past five years?** Yes No If yes, please explain in the space below. Indicate whether conviction was a misdemeanor or a felony. Note * Conviction of a motor vehicle violation or crime will not automatically result in your disqualification. The seriousness of the offense and the date of conviction will be considered in relation to the particular position(s) available or for which you have applied. Volunteer Applicant's StatementI certify that all of the above information on this application and on all other volunteer-related documents that I have submitted is true and complete. I understand that any misrepresentation or omission may result in my disqualification from further consideration for volunteering or my termination from volunteering. Further, in order that Riverbend Community Mental Health Services, Inc. may process my application for volunteering, I hereby authorize Riverbend Community Mental Health Services, Inc., its subsidiaries, officers, directors, employees, representatives, and agents (hereinafter collectively referred to as “Riverbend”) to conduct a complete investigation into my background including, but not limited to, inquiring into my employment history, including my fitness for duty at all prior volunteer opportunities; education history; credit history; criminal record and military record, if any; to obtain opinions and references regarding my moral character and reputation and to solicit and obtain any other information Riverbend in its sole discretion deems as necessary to determine my eligibility for volunteering or for the purposes of confirming the accuracy and completeness of any information I provided to Riverbend. In consideration for the processing of my application for volunteering with Riverbend, I hereby release, indemnify and hold harmless Riverbend from any and all liability based on their authorized receipt, disclosure, and use of the information gathered in the processing of my application for volunteering. I further release from liability any person or organization that provides information concerning me. By my signature, I acknowledge that I have read and understand the foregoing and so authorize and release Rirverbend.Electronic Signature Today's Date MM slash DD slash YYYY Δ
