Volunteer Application

Volunteer Application
Your Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
State of Birth*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Availability

Please select the days and times that you would be available to serve.

Your Availability*

	8am-9am	9am-10am	10am-11am	11am-12pm	12pm-1pm	1pm-2pm	2pm-3pm	3pm-4pm	4pm-5pm	5pm-6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please select the areas that you would be interested in serving.*

Office Support (filing, answering phones, preparing/mailing letters)FIT Support (providing child care for Life Skills Classes, providing food for life skills classes, organizing or delivering donations made to the Families In Transition program)Assisting with Care of Physical Plant (moving furniture, apartment get ready for Families In Transition units)Literacy Program TutorHomework Assistance (Assist in aiding Agape assisted children in the completion of their homework and studies)

References

Please list your references and their contact information below.
Reference #1
Name*
E-mail*
Phone Number*

Area CodePhone Number
Relationship*
Reference #2
Name*
E-mail*
Phone Number*

Area CodePhone Number
Relationship*
Reference #3
Name*
E-mail*
Phone Number*

Area CodePhone Number
Relationship*

Emergency Contact Information

In the event of a medical emergency, by signing this form, I confirm to the necessary and proper treatment, surgery, and/or anesthetic by a licensed physician or health care professional for the in the individual named on this form. Volunteers will not be covered by Agape Child & Family Services medical insurance plan. Please provide two people who we can contact in case of an emergency:
Emergency Contact #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Liability Agreement*

By signing this form I confirm that I understand that if I am injured during a volunteer assignment with Agape Child & Family Services the organization is not responsible for any and all medical costs.

Driver License Information

Please fill out the information below and check the release agreement to give us permission to your drivers license information.
Your name as it appears on drivers license:*

First NameLast Name
Maiden Name
If currently married
Date of Birth*

MonthDayYear
State Issued*
Drivers license Number*
Race*
Gender*

MaleFemale
Age*
Hair Color*
Eye Color*
Height*

FeetInches
Weight*
Social Security Number*
Driver Records Release:*

I hereby give consent, without reservation, for AGAPE Child and FamilyServices, Inc. and its employees to obtain a copy of my driving record as part of the foster, volunteer, and/oradoptive background check. That a telephonic facsimile (FAX) or photographic copy shall be as valid as the original.

Liability & Agreements
Release of Liability:*

By checking this box, I confirm that I am aware of the potential risks to my property and me during my volunteer assignment with Agape Child & Family Services. With such knowledge, I voluntarily release and will indemnify Agape Child & Family Services, their representatives, and employees from any and all liability related to my activities with this program, including any liability arising out of negligence.
Release of Information/Consent:*

AGAPE Child and Family Services, Inc. is required by the Tennessee Child Abuse Law (TCA 37-1- 408) to inquire if a volunteer has ever been convicted of a felony.Therefore, I grant approval for AGAPE to request information on any and all records of arrest and/or convictions. I hereby release the Country Sheriff’s or Police Department, its officers, agents, employees, successors, and assigns from any and all claims, actions or suits for damage or injuries, of whatever nature, which may result from release of my police records upon this request. Further, I understand and consent to provide my fingerprints as requested and hereby authorize any governmental authorities to check my fingerprints against their databases and release any information obtained from such check to AGAPE.
Any information obtained from a volunteer may be stored with a third-party entity for purposes of maintaining electronic data, and the third-party entity will be responsible for maintaining the confidentiality of such information.
Should be Empty:

Volunteer Application

Availability

References

Emergency Contact Information

Driver License Information

Liability & Agreements