Collegiate Ymca Volunteer Application Form (Page 2 of 2) in pdf

Special Certificates/Licenses/Qualifications/Degrees _________________________________________________________

Other relevant skills or experience ________________________________________________________________________

References

(2 Personal and 2 Professional - REQUIRED)

NOTE: The YMCA checks references on all volunteers, as such the following information is required of all applicants.

PERSONAL REFERENCES

HOW LONG HAVE YOU

NAME

PHONE

E-MAIL

RELATIONSHIP TO YOU?

KNOWN THIS PERSON?

PROFESSIONAL REFERENCES

HOW LONG HAVE YOU

NAME

PHONE

E-MAIL

RELATIONSHIP TO YOU?

KNOWN THIS PERSON?

REQUIRED INFORMATION

Have you ever been convicted of a crime? (Exclude any marijuana offenses that are over two years old and minor traffic violations for

which the fine was $100.00 or less).

YES

___________________________________________________________

If yes, please state the date, location, and circumstances

___________________________________________________________________________________________________________________________

NOTE: The existence of a criminal record will not constitute an automatic bar to volunteering.

Are you a registered sex offender?

YES

Agreement

I hereby certify that all answers and statements made on this application are complete and true to the best of my knowledge. I am not a pedophile or child

molester and have not been convicted of either. I understand that any misleading, misrepresentation and/or omission of information will cause this

application to be rejected and will be grounds for discharge. I further understand that final volunteerism is based on completion of all volunteer screening

requirements and procedures, including interview(s), reference checks, verifications, physical examination and fingerprinting.

I authorize all organizations and persons named above to give information about me and I hereby release them of all liability. I have carefully read and

understand this application and, by my signature below, consent to the release of consumer or investigative consumer reports (fingerprints) to the YMCA in

conjunction with my application for volunteering. I further understand that any and all information contained in my volunteer application or otherwise

disclosed to the YMCA by me before, during or after my volunteerism, if any, may be utilized for the purpose of obtaining the consumer reports (reference

checking) or investigative consumer reports requested by the YMCA.

If I am engaged as a YMCA Volunteer, I agree to observe all rules, regulations, policies and procedures as they relate to the YMCA of Greater Pittsburgh

employees at all times. I also understand that, although I may be volunteering for a particular position and shift, it may be necessary to accept different

assignments, schedules or hours.

I hereby certify that all of the facts set forth in my application are true and complete. I understand that if I am engaged as a YMCA Volunteer, false

information on this form or failure to disclose material facts will be considered grounds for discharge. I further understand that my services are on a

volunteer basis for which no compensation is provided, and that these services are at-will and may be terminated at any time by either party.

Signature: __________________________________________________________________ Date: __________________

Signature of Parent or Guardian: ______________________________________________ Date: ___________________

(if you are under 18)

Please return this completed application form to:

Collegiate YMCA, a Branch of the YMCA of Greater Pittsburgh

311 Bellefield Hall, Pittsburgh PA 15260

Phone: 412-648-7960

Fax: 412-624-3795

ymca@pitt.edu

Again, thank you for your interest!!

HR/VOL 3/03