VOLUNTEER APPLICATION

Name: Date

Address: City: State: ZipCode:

Phone: Home: Work: E-mail:

Can phone number be published at Harbor House?

Emergency Contact: Phone:

How did you hear about the volunteer opportunities at Harbor House?

What volunteer opportunities interest you most:

CURRENT SOCIAL INFORMATION:

List activities you are presently involved in:

Skills/hobbies/special interests:

Please list other volunteer experiences (past or present):

Why do you want to volunteer for Harbor House Domestic Abuse Programs?

Your Occupation:

Employer:

 

EDUCATIONAL BACKGROUND:

List years of schooling:

Please list degrees and major fields:

List any related courses or experience (volunteer or professional) which you feel would assit you in being a volunteer with this organization:

What languages do you speak?

How comfortable are you with this language?

REGISTRATION INFORMATION:

Driver's License State: Expiration Date:

Do you have a car at your disposal? Do you carry minimum liability insurance on your car?

Have you received any traffic violations in the last four years?

Have you ever been arrested and/or convicted of a criminal offense? If yes, specify the type of offense:

REQUIRED FOR CRIMINAL BACKGROUND CHECK

During the interview you will be asked to provide your social security number and date of birth.

GENERAL SCHEDULING INFORMATION:

Approximately how many hours per month are you able to volunteer?

Indicate the best times (approx.) for your to volunteer (you may check more than one)
Morning 9:00-1:00
Afternoon 1:00-5:00
Evenings 5:00-9:00
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

REFERENCES:

Please list three. Name/address/phone number/relationship

Name: Phone:
Address: Relationship:
Name: Phone:
Address: Relationship:
Name: Phone:
Address:

Relationship:

CONFIDENTIALITY POLICY:

The primary purpose of the Harbor House Domestic Abuse Programs is to provide protection and safety to victims and the children of victims. The use or disclosure of any information by anyone affiliated with Harbor House (staff, volunteers, board members) that concerns the victims or the children of victims who receive services from Harbor House for any purpose is prohibited by state law. It is, therefore, a policy of the Harbor House Domestic Abuse Programs that any agent of Harbor House (staff, volunteers, board members) will treat all contacts and information regarding victims and children of victims who receive services from Harbor House as confidential. No information Regarding service recipients will be divulged either directly or indirectly to anyone.

This includes:

  • Harbor House Domestic Abuse Programs may not contact the perpetrator nor may they require that the victim contact the perpetrator.
  • Harbor House may not reveal the victims or the victim's children's whereabouts, or require the victim to reveal such whereabouts.
  • Files and all written documents regarding victims and the children of victims are to be maintained in a confidential manner.
  • Victims will be informed of their rights to confidentiality during the intake process.
  • Staff, volunteers and board members are still bound by this condition of confidentiality upon completion of employment, volunteer commitment or board term once this form is signed.

 

CONFIDENTIALITY PLEDGE AND AGREEMENTS:

By clicking the submit button:

  • I hereby affirm that I have read the above policy and do fully realize the importance of maintaining confidentiality. I understand that there is a state law prohibiting disclosure (section i, 895.67.) I agree to abide by this policy.
  • I hereby authorize Harbor House Domestic Abuse Programs to contact the above references to determine if I can become a volunteer.
  • I give permission to Harbor House Domestic Abuse Programs to perform a criminal background check in order to determine if I can become a volunteer.
  • The information that I submitted on this application is true and correct to the best of my knowledge.

 






24 hour helpline (920) 832-1666 Fox Cities / (920) 849-7819 Calumet County
toll free (800) 970-1171

Harbor House Domestic Abuse Programs, Inc.