Step 1 of 3 – Applicant Information 33% CHILDCARE VOLUNTEER APPLICATION Thank you for your interest in volunteering at Child & Family Agency! Please answer the questions below and return to CFA at your convenience. Date of application(Required) MM slash DD slash YYYY Applicant InformationApplicant Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone / Primary phone(Required)Email(Required) Are you a college student?(Required) Yes No If yes, which college are you currently attending? What is the best way to contact you?(Required) Phone Email Text VOLUNTEER INTEREST AREASPlease check the volunteer area(s) that interest you below.Area of Support(Required) Direct Service with children Other Age Group(Required) Infant/Toddler Preschool (ages 3-5) Other:(Required) RELEVANT PAST VOLUNTEER / EMPLOYMENT EXPERIENCE Attach resume or additional sheet if needed. Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Place/Location Description of Duties/ResponsibilitiesInclude a second past volunteer/employment experience Yes No Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Place/Location Description of Duties/ResponsibilitiesInclude a third past volunteer/employment experience Yes No Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Place/Location Description of Duties/ResponsibilitiesSchedule of Times Available to Volunteer(Required)Please select times you are available, on the following days, to volunteer: Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Please indicate any languages (other than English) you can speak, read, and/or write: Spoken language(s)FluentGoodFair Add RemoveReading language(s)FluentGoodFair Add RemoveWritten language(s)FluentGoodFair Add RemoveAre you enrolled in or have you completed any college-level courses appropriate to the volunteer position you are seeking? If yes, please list below: Are there any other skills or abilities that you possess which you feel would be beneficial to Child & Family Agency? Applicant’s Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary in arriving at a placement decision. This application for placement shall be considered active for a period of time not to exceed one year. Any applicant wishing to be considered for placement beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any placement relationship with this organization is of an “at will” nature, which means that the Volunteer may resign at any time and the Agency may discharge Volunteer at any time with or without cause. It is further understood that this “at will” relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of placement, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Agency. Signature of Applicant(Required) Type nameDate of signature(Required) MM slash DD slash YYYY Criminal History Check NOTE TO APPLICANT: A criminal background check is necessary as part of our application process. * PLEASE NOTE WHEN ANSWERING THE FOLLOWING QUESTIONS: Under CT law employers may not require disclosure of an arrest, criminal charge or conviction for which records have been erased; Any person whose criminal records were erased will be considered to have never been arrested or convicted for such matter(s), and may swear so under oath concerning such erased records; The type of criminal records subject to erasure are those pertaining to: a finding of delinquency of that a child was a member of a family with service needs; a sentence as a youthful offender; a criminal charge that was dismissed or nulled; a criminal charge for which the person was found not guilty; and a conviction for which the person received an absolute pardon. Have you ever been convicted of a felony, or a sex related or child abuse related offense?(Required) Yes No I hereby give permission for the Child and Family Agency of Southeastern CT, Inc. to conduct a criminal background check (post placement offer) for any record of a felony conviction. I agree to fully cooperate in any such background investigation, and to sign any waivers or releases that may be necessary to obtain access to relevant information. In the event that any custodian of data will not release reference information or criminal history information directly to the Company, I agree to personally request such information to the extent permitted by law. I understand that any conviction record(s) discovered during such investigation will be kept confidential and will not be disclosed to anyone except those Company personnel representatives with a need to know based on management responsibilities or involvement with the hiring process.Signature of Applicant(Required) Type nameDate(Required) MM slash DD slash YYYY
