The Shelter for Abused Women & Children | 2023 Volunteer Interest Form

Date

Name *

First

Last *

Last

Email *

Address *

City *

State *

ZIP code *

Are you a seasonal resident? *

Yes

No

Typical residency dates in Naples (example: October to April)

Non-local address

City

State

Zip code

Phone (home) (cell) *

Date of Birth

Driver's License Number (NA if you do not have a driver's license) *

Emergency contact/relationship/phone

I would like to receive The Shelter's e-newsletter *

Yes

No

I would like information on joining The Shelter Guild

Yes

No

Start Date

Number of hours of commitment per week:

Your preference for hours

Your preference for days

Which do yo prefer?

To be scheduled

To be on call

Choose areas of interest (* indicates additional training and background check may be required)

Education Background:

Current/Previous Occupations

Hobbies/Skills/Interests:

Current/Previous Volunteer Experience:

Are you multilingual? If yes, please list languages spoken

PERMISSION TO PERFORM BACKGROUND CHECK *

Yes

No

I hereby allow SAWCC, Inc. to perform a check of my background, including:  Criminal Record, Driving Record, Educational/Professional Status, Personal References. I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for volunteering. I understand that information collected during this background check will be limited to what is appropriate for particular types of volunteer work. All such information collected during the check will be kept confidential. I hereby extend my permission to those individuals or organizations contracted for the purpose of this background check to give their full and honest evaluation of my suitability of the described volunteer work and such other information as they deem appropriate.

BACKGROUND CHECK ELECTRONIC SIGNATURE *

DATE *

CONFIDENTIALITY AGREEMENT (required) *

Yes

No

I understand that as a visitor of The Shelter for Abused Women & Children (The Shelter), I will encounter participants whose confidentiality should be protected. I will protect all participants’ confidentiality including any and all information known or disclosed to me, including but not limited to participant(s) name(s), location, and any other identifying information. I agree that I will neither acknowledge nor disclose any information about participants of The Shelter to anyone other than the employees of The Shelter.

CONFIDENTIALITY AGREEMENT ELECTRONIC SIGNATURE

DATE *

What attracted you to The Shelter and how did you hear about us?

Do you have any physical limitations or are you under any course of treatment which might limit your ability to perform certain types of work?

Have you ever had any personal experience with violence (answer only if you wish to do so)

NOTE

*The Shelter for Abused Women & Children Complies with section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, as implemented by 45 C.F.R. Part 84 (hereinafter referred to as Section 504) and the Americans with Disabilities Act of 1990, 42 U.S.C. 12131, as implemented by 28 C.F.R. Part 35 (hereinafter referred to as ADA)According to the requirements of Title VI of the Civil Rights Act of 1964, clients with limited English proficiency or hearing impairment have the right to receive FREE language interpretation, translation and other accommodations in order to access information and services, regardless of race, gender, country of origin, and religion. If you are in need of language assistance, including translation, interpretation or other accommodations, please let us know – this service will be provided to you at no cost. A TTY (Telecommunication Device for the Deaf) telephone line is available at The Shelter for residents who may be hearing impaired and Braille signage is used throughout the building.

Please list two non-family references who we might contact. Please list name and contact number.

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