Name: ___________________________________________
Address: ________________________________
Street
___________________ Phone (h): ____________________
City
___________________ Answering machine: ____ yes ____
no
Postal Code
Email: _______________________
AGE RANGE: less than 50 _____
50 - 60 ______ 60+
______
(for research
purposes)
Use
of car: ____ yes ____ no
Emergency Contact: ____________________________
Relationship: ______________________
Phone (h): ____________________ Phone (w): ____________________
Do you have any Medical or Physical limitations you wish to be taken into
consideration, or that you feel may affect your ability to perform as a senior
associate in a family literacy program?
____ yes ____ no
If yes, explain briefly:
Volunteer/work
experience:
Hobbies/interests/skills:
Reason for
volunteering:
Once you begin the
volunteer commitment is on a regular basis for a block of time (usually 6 weeks
– maximum 2 hours each day)
Time available: ____ Morning ____ Afternoon ____ Evening ____ Weekend
Availability: length of
initial commitment _____ months _____ weeks
What types of
activities would you be interested in doing within family literacy programs?
What special
strengths would you bring to this volunteer position as a senior associate?
How did you hear
about this volunteer opportunity?
Since
we take our responsibility for our family literacy programs seriously, we
screen all our applicants for Senior Associates thoroughly. ILLAG requires two personal and/or
professional references for all positions in Family Literacy programs.
Consent
of referees must be attained prior to contact by ILLAG project
facilitator.
All
information will be kept in the strictest of confidence.
While attempts are made to place every applicant,
management reserves the right to not accept an applicant.
References:
1) Name:
__________________________ Phone: ___________________
Relationship: _____________________
2) Name:
__________________________ Phone: ___________________
Relationship: ____________________________
I consent to the gathering of this information for
the sole purpose of contact and placement as a volunteer in the family literacy
programs.
I also verify that all of the above information
provided is true and complete.
I hereby authorize the ILLAG project facilitator
to contact the above names references to ascertain my suitability as a senior
associate.
Applicant’s Signature __________________________ Date
_____________________
OATH OF
CONFIDENTIALITY
I ________________________________,
affirm that in whatever function I may perform as a Senior Associate with
family literacy programs or any other related activities with the
Intergenerational Literacy Links Project
I will:
Not
discuss any case material, history, or other information concerning the
participant(s), and/or staff with whom I am involved, other than with the authorized personnel
or designated program facilitators.
Such discussions, as
required, are to be carried out in the strictest confidence.
Witness Signature of Senior Associate
Date
ILLAG use only:
Date of interview: ______________ Interviewer:
___________________
Initial placement program/location: _________________________
Child Abuse Registry Check: _____ in process _____ returned
Comments: