Volunteer Application Form (Page 4 of 4) in pdf

APPLICANT’S STATEMENT OF AFFIRMATION

I have read and agree to abide by the Volunteer Behavioral Code and Coach’s Creed. I understand that if I am in violation of

any of the YMCA’s codes of conduct, I will be subject to disciplinary action up to and including termination as a YMCA volunteer.

In addition, I understand and agree that I may be removed as a volunteer by the YMCA at any time and for any reason in the

YMCA’s sole discretion.

I hereby affirm that I have accurately completed this volunteer application. My answers to all the questions are true and correct

and I have not knowingly withheld any fact or circumstance that may, if disclosed, affect my application unfavorably. I

understand that any false or incomplete information submitted in this application may result in my termination as a YMCA

volunteer.

I hereby give my permission for the YMCA to utilize the services of an outside agency to obtain a security checks report,

including a check of my criminal history, motor vehicle record, and social security number verification as part of the procedure

for processing my application for volunteering. I understand that before I am denied the opportunity to volunteer based on

information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Fair

Credit Reporting Act. I understand that if I disagree with the accuracy of any information in this report, I must notify the YMCA

within five days of my receipt of the report. If I notify the YMCA within five days of the receipt of the report that I am

challenging information in the report, the YMCA will not make a final decision on my volunteer status until after I have had a

reasonable opportunity to address the information contained in the report. I understand that my volunteering with the YMCA is

conditional based on the results of a criminal record check and MVR Report and that the YMCA has sole discretion in making

this decision. Finally I authorize the YMCA to repeat the criminal history and motor vehicle records check at any time.

Signature: ____________________________________________________ Date: ____________________

If under the age of 18, Parent/Guardian’s Signature ___________________________________________ Date: ____________________

Thank you for sharing your time and talents with the YMCA! Your volunteer efforts help the YMCA

to successfully meet its mission.

No one is turned away from the YMCA due to an inability to pay a program or membership fee. Need-based financial

assistance is available through our ‘Open Doors’ Program.

Our Mission: Helping people reach their God-given potential in spirit, mind and body.

Revised/Printed 02-2009

Volunteer Application Form Page 4