Volunteer Application Form Page 2
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2REFERENCES
Please list three personal references.
NAME________________________________________________________ RELATIONSHIP_____________________________________ PHONE #________________________________________
NAME________________________________________________________ RELATIONSHIP_____________________________________ PHONE #________________________________________
NAME________________________________________________________ RELATIONSHIP_____________________________________ PHONE #_______________________________________
EDUCATION AND TRAINING
HIGH SCHOOL ATTENDED
_________________________________________________________________________ CITY, STATE ____________________________________________
DID YOU GRADUATE OR RECEIVE A GED? ____YES
___NO ___STILL ATTENDING
COLLEGE OR UNIVERSITY ATTENDED
______________________________________________________ CITY, STATE ______________________________________________
DID YOU GRADUATE OR RECEIVE A GED? ____YES
____NO
____STILL ATTENDING
DEGREE ATTAINED:____________________________________________________
COLLEGE OR UNIVERSITY ATTENDED
_____________________________________________________ CITY, STATE _______________________________________________
DID YOU GRADUATE OR RECEIVE A GED? ____YES
____NO
____STILL ATTENDING
DEGREE ATTAINED:_____________________________________________________
ADDITIONAL TRAINING OR CURRENT CERTIFICATIONS HELD
______________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________
VOLUNTEER STATEMENT
Have you ever volunteered for the YMCA of Marion & Polk Counties before?
____Yes
____No
If so, please provide details___________________________________________________________________________________________________________________________________
Have you ever been employed by the YMCA of Marion & Polk Counties before?
____Yes
____No
If so, please provide details___________________________________________________________________________________________________________________________________
Have you ever been convicted of a felony?
____Yes
____No
If yes, please explain____________________________________________________________________________________________________________________________________________
Have you had any criminal convictions for child abuse or sex-related crimes?
____Yes
____No
If yes, please explain____________________________________________________________________________________________________________________________________________
If selected as a volunteer, would you agree to sign a Volunteer Code of Conduct?
____Yes
____No
If selected as a volunteer, would you agree to a criminal background check?
____Yes
____No
APPLICANT AGREEMENT
I certify that the information in the application is correct and complete to the best of my knowledge.
Acceptance into the volunteer program with the YMCA of Marion and Polk Counties is contingent upon satisfactory pre-placement
procedures which include, but may not be limited to, an interview, verification of references, criminal background check, and
training.
I realize that misrepresentation of facts will be cause for rejection of this application. In the event of placement in the volunteer
program, falsification of any information on the application will be cause for dismissal.
I authorize the YMCA of Marion and Polk Counties to verify the information provided on this application and to conduct a criminal
background check. I will hold no person liable for giving or receiving information regarding this application.
I agree to abide by the policies of the YMCA of Marion and Polk Counties.
SIGNATURE OF APPLICANT_____________________________________________________________________________
DATE_________________________________________
SIGNATURE OF PARENT
DATE______________________________________________
_____________________________________________________________________________________________________________________
(IF APPLICANT IS LESS THAN 18 YEARS OLD
Family YMCA of Marion & Polk Counties, 685 Court St. NE, Salem, Or 97301
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