WYN Volunteer Application

Contact Information

First Name *This question is required.

Last Name *This question is required.

Preferred Name *This question is required.

Pronouns

Mailing Address *This question is required.

Apt/Suite

City *This question is required.

State *This question is required.

Zip *This question is required.

Is your physical address different than your mailing address?

What is your physical address?

Physical Address
Apt/Suite
City, State, Zip

Email Address *This question is required. This question requires a valid email address.

Mobile Phone

D.O.B *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Emergency Contact Information

Name

Relationship

Company Name

Phone Number

Some sites are located 8-10 miles outside of town. You must provide your own transportation. Are you willing to do so?

Why are you interested in volunteering? *This question is required.

What days are you available? (Check all that apply) *This question is required.

Please list any experience you have in working with young people and include approximate dates of experience:

List any other volunteer experiences:

What are your hobbies, skills, special talents, interests, etc?

Please mark which program you are interested in working with: *This question is required.

Education (Indicate schools, majors, degrees, etc):

Are these volunteer hours required for a specific college course? *This question is required.

Class Name:

Professor/ Instructor:

Day-Time Contact Number:

Approximate number of hours needed:

List four references (Required for all programs working with youth):
None of which are related to you or are family friends and must have known you for at least 1 year.
References could include: employer, volunteer supervisors, professors, religious leaders
***Please alert all your references that they will be receiving a call from us!

Reference 1

Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Reference 2

Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Reference 3

Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Reference 4

Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

NCDL#

Auto Insurance Carrier:

Insurance Expiration Date: This question requires a valid date format of MM/DD/YYYY.

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Family Status: *This question is required.

Spouse's Name:

Names and ages of children in home:

Do you take illegal drugs? *This question is required.

Do you have any history of excessive use of any drugs (over the counter, prescription, and/or alcohol)? *This question is required.

Have you ever been in treatment (for alcohol or drug use or emotional problems)? If so, when? *This question is required.

Background checks are required to work with WYN youth. As you know, WYN is a non-profit organization, and these checks cost $18 for after school volunteers, and $30 for mentors. If you are able/willing to contribute any, or all of the cost for yours, please check the amount below:

After School Volunteers: $18
Mentors: $30

*Please discuss with us other payment options if necessary (We don’t want this to discourage you from volunteering at WYN)*

I certify that all information on this application is true. I understand that any false statements or withheld information on my part will be reason to disqualify me from serving as a volunteer. I also hereby give my permission for WYN to produce or utilize any media including: photographs, films, visual recordings, or written accounts of statements for the use of any or all activities authorized by Western Youth Network. I give my permission to program staff to contact the references I have listed. *This question is required.

Clear

Signature of

ASSURANCE OF CONFIDENTIALITY

I agree to maintain the confidentiality of consumers and their families, as well as any other person’s involved with the Western Youth Network. I agree that all information acquired in the course of attending or treating a consumer of the agency shall be held confidential. Release or disclosure of this information shall be prohibited except under the conditions specified in the Policy and Procedure manual section 3.5. Individuals, other than employees but including students and volunteers, who are agents of Western Youth Network, Inc. who have access to confidential information who fail to comply with the rules shall be denied access to confidential information by the company. I am aware that I may discuss pertinent confidential information with Western Youth Network staff only. I acknowledge that I have been made aware of the penalties and disciplinary action for improper release of Western Youth Network confidential information.

*This question is required.

Clear

Signature of

Please mark any of the following that you feel may prevent you from fulfilling the required time commitment of 2 hours a week for one year:

Employment
Extend Trips
School
Other (please indicate) Please enter an 'other' value for this selection. * This question is required.

Please select the box below if you would not like to receive free monthly email updates from WYN. Past updates have included touching success stories, event updates and fresh perspectives on topics related to youth and community development. If you do not select the box below, WYN will add your email address to its monthly email contact list.