Volunteer Application

Name:

Email:

Phone:

Address

How long have you lived at this address?

Name of Employer

Title/Position

Educational Background/Training

Volunteer Experience

Please list 3 professional references that we may contact. List name, email and relationship.

Why are you interested in volunteering for Pohl Childrens Foundation

Which volunteer position(s) are you interested in:

What special skills would you like to share with Pohl Childrens Foundation as a volunteer?

Do you speak, sign, read or write any languages other than English?

Emergency Contact Information. Please list name and phone number.

Notice of Intent to Verify Background Information *

I agree. In connection with my application for volunteering with Pohl Childrens Foundation, I understand that a consumer report will be requested to verify my identity through my social security number. I also understand that you will be requesting information concerning my criminal history from various states of residency.

Confidentiality Satement*

I Agree. I acknowledge that Pohl Childrens Foundation is an agency whose purpose is to provide support and services to children and their families as they deal with serious illnesses and/or death. I hereby agree to follow the strictest of ethics when trusted with confidential information. This confidential information includes, but is not limited to : the identities of Pohl Children Foundation participants, files pertaining to families, information concerning the organization, volunteers and/or staff, and information received from interviews, one on one visits, support groups, or special events.

Media Release

I Agree. I authorize Pohl Childrens Foundation to use my photograph, name and/or information about me regarding my volunteer service providing support to children and their families as they deal with serious illnesses and death . I understand that media may include but is not limited to newspaper articles, television, radio, and speaking engagements.

Consent *

I Agree. I have completed and reviewed thsi entire form and attest that the information provided is true. I also grant permission for Pohl Childrens Foundation to obtain information from my references and/or other volunteer organizations with which I have worked that may be pertinent to my application.

Applicant Signature*

Volunteer Application

Volunteer Application

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