Application For Participation In Special Olympics Unified Sports Partner (Page 2 of 2) in pdf

SPECIAL OLYMPICS IDAHO

VOLUNTEER REGISTRATION APPLICATION

SECTION 1:

Please Print

Name: Mr/Mrs/MS/Dr_________________________________________________________________________________________________________________________

(Circle One)

Last Name

First Name

Middle Initial

Gender

Mailing Address:

_________________________________________________________________________________________________________________________

Number

Street

Ste/Apt/#

____________________________________________________________________________________________________________________________________________________________

City

State

Zip Code

_____________________________________________________________________________________________________________________________________________________________

Phone (Daytime)

Phone (Evening)

Best time to call

e-mail

_____________________________________________________________________________________________________________________________________________________________

Date of Birth

Social Security Number

Driver’s License Number

Team Information: __________________________________________________________________________________________________________________________

Area

Team Name

Position

Sport

Employment/School Information: _______________________________________________________________________________________________________________

Employer/School Name

Occupation

Employer /School Address: ____________________________________________________________________________________________________________________

Number

Street

Ste/Apt/#

______________________________________________________________________________________________________________________

City

State

Zip Code

IN ORDER TO PROCESS THIS APPLICATION, WE NEED ONE OF THE FOLLOWING:

Local Program Coordinator’s validation signature, indicating he/she has checked your driver’s license:___________________________________________________

A photocopy of any form of photo identification card, preferably your driver’s license.

(Please attach to application)

If you have not lived in Idaho for at least 3 years, please list the state of your previous residence:__________________________________________________________

Have you volunteered for Special Olympics before?____________ If yes, where and in what capacity?______________________________________________________

SECTION II:

1) Do you use illegal drugs?

Yes________ No________

2) Have you ever been convicted of a criminal offense?

Yes________ No________

3) Have you ever been charged with neglect, abuse or assault?

Yes________ No________

4) Has your driver’s license ever been suspended or revoked in any state?

Yes________ No________

List 2 non-family references:

NAME

RELATIONSHIP

FULL ADDRESS AND PHONE NUMBER

1)______________________________________________________________________________________________________________________________________

2)______________________________________________________________________________________________________________________________________

SECTION III: PLEASE READ BEFORE SIGNING:

I understand that:

•

The information that I have provided may be verified, and I give permission to Special Olympics to make inquiry of others concerning my suitability to act as a Special Olympics

volunteer including a check of criminal history and driver’s license record.

•

In the course of volunteering for Special Olympics, I may be dealing with confidential information and I agree to keep said information in the strictest confidence.

•

The relationship between Special Olympics and volunteers is an “at will” agreement, and may be terminated at any time without cause by either party.

•

It is my responsibility to update the information on this form as needed.

•

I grant Special Olympics permission to use my likeness, voice and words in television, radio, film, or in any other form to promote activities of Special Olympics.

I affirm that I have read all of the information on this Volunteer Registration Application and on the Release and Waiver of Liability of Risk and Indemnity

Agreement on the reverse of this page and that the information I have given is true and complete. I further understand that my signature must appear on both

sides of this form before my Application will be processed.

Signed:__________________________________________________________________________________________________________Date:__________