CEDARS : Join Our Team : Volunteer : Volunteer Online Application

In order for application to be processed, you MUST print off "Release of Information" (on previous page) and return to CEDARS, 620 North 48th St. Suite 100, Lincoln, NE 68504

Name:

Current Address Street:

City, State, ZIP:

Permanent Address, Street:

City, State Zip:

Email Address:

Home Phone:

Cell Phone:

Driver's License Number:

Social Security Number:

Date of Birth:

Sex:

	Male
	Female

Occupation/Employer:

Are there any health issues or physical limitations that could affect volunteer work or require placement modifications:

	Yes
	No

If yes, please describe:

Have you ever been arrested or charged, other than minor parking violations:

	Yes
	No

If yes, please describe:

Have you ever been convicted of a felony:

	Yes
	No

If yes, please describe:

If volunteering for diversion services, please state your offense, contact person and required hours:

Volunteer Work Experience:

Special Interests/Hobbies:

Education, highest grade completed:

Degree Attained:

Degree Attained From:

Major:

Minor:

If volunteering for school credit, name of Instructor:

School Name:

Address:

Phone:

Number of hours needed for class:

REFERENCES (other than relatives)

(Please provide complete addresses for all references listed)

Reference #1:

Phone:

Relationship:

Address:

City, State, ZIP:

Reference #2:

Phone:

Relationship:

Address:

City, State, ZIP:

Reference #3:

Phone:

Relationship:

Address:

City, State, ZIP:

In case of an emergency contact (Name):

Address:

Day-Time Phone:

Alternate Phone (cell, home, work):

In case of an emergency contact (Name) :

Address:

Day-Time Phone:

Alternate Phone (cell, home, work):

Your Doctor's Name:

Your Doctor's Phone Number:

How did you hear about CEDARS and why are you interested in volunteering with us:

What would you consider to be the ideal volunteer job for you:

Describe any special training/experience that might enhance your work as a volunteer:

What is your definition of boundaries when it comes to working with children/youth:

Briefly describe your approach to teamwork:

Are there any issues which may arise in a family which you would be uncomfortable working with (drug/alcohol abuse, physical abuse, sexual abuse):

Describe what you have done that has given you the greatest satisfaction:

What is your school/work schedule? What are you able to commit to:

Is there anything else that you would like CEDARS to know about you:

What (if any) foreign language do you speak fluently:

I understand that as a condition of my volunteer/employment/contractor, my name will be checked against the Nebraska Department of Health and Human Services Adult/Child Protective Services Central Registries. A check of these registries is necessary to ensure that I meet provider standards. One copy of this form will be sent to the Adult Registry and one will be sent to the Child Protective Service Registry, s they are two separate areas.

The purpose of this check will determine if my name is being maintained on either registry as a result of previous abuse/neglect allegations which have been investigated and have been determined to be unfounded.

To the best of knowledge, I do not have a conviction or prior history of adult or child abuse/neglect or maltreatment. Neither have I been convicted of a crime involving moral turpitude.

I hereby authorize the Nebraska Department of Health and Human Services to release information contained on the Adult or Child Protective Services Central Registry including the information that a record has been found to:

Authorize:

	Yes
	No

Other Names Used:

Other Addresses in Past Twenty (20) Years:

Names of Children Who have Lived With You:

Applicant Date of Birth:

Current Street Address/City/Zip:

DEMOGRAPHIC INFORMATION

We request your cooperation in completing the following voluntary applicant demographic information. This information will not be used in making any decision affecting employment or any personnel action following employment. It will be used to complete records required of CEDARS by governmental authorities.

Today's Date: Mo/Day/Yr:

Name: Last/First/M.I.:

Gender:

	Male
	Female

Date of Birth: Mo/Day/Yr:

Social Security Number:

Recruitment Source:

Position Applying for:

Ethnic Background:

	WHITE (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
	BLACK (not of Hispanic origin): All persons having origins in any of the black racial groups of Africa.
	HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central of South American, or other Spanish culture or origin, regardless of race.
	AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the people of North America, and who maintain cultural identification through tribal affiliation or community recognition.
	ASIAN OR PACIFIC ISLANDERS: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or Pacific Islands. For example, China, Japan, Korea, the Philippines Islands, and Samoa.

Do you have a physical or mental disability:

	Yes
	No

If yes, please explain:

Citizenship or Immigration Status:

	U.S. Citizen
	Immigrant alien (admitted to the U.S. for lawful permanent residence) with Alien Registration Receipt form I-551
	Non-immigrant alien (admitted to the U.S. temporarilyfor specific purpose).

GENERAL QUESTIONS

How did you hear about our volunteer opportunities:

CERTIFICATION OF APPLICANT

By submitting this form, you certify that your answers on this application are true and complete to the best of your knowledge. You also grant your permission and consent for us to contact the necessary resources and references to verify your responses on this application.

Colored fields indicate required information.

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