Individual Volunteer Application Form - Ray Graham Association

Last Name

First Name

Date Of Birth

Address

City

State

Zip Code

Home Phone Number

Cell Phone Number

Email Address

Company or Volunteer Group Name (if applicable)

Place of Employment

Job Title

Emergency Contact

Relationship

Contact Phone Number

Phone Number Type

Do you have any friends/family members who are employed or volunteer at RGA?

Yes

Court Ordered?

Yes

When are you available to volunteer?

Location Preference

Available Start Date

Types of volunteer work you are interested in

I need the following accomodation(s) to work as a volunteer:

Have you ever been adjudged civilly or criminally liable for abuse of an individual with disabilities?

Yes

Have you been convicted of a crime?

Yes

BACKGROUND CHECK: Volunteers are required to submit to a background check with the State of Illinois. Court ordered volunteers are required to pay the $10 fee. Screening must be completed before volunteers begin working with people served.

I agree to have a background check.

Volunteer Digital Signature: I certify that my answers on this application are true and complete and that I have not knowingly withheld any information that might, if disclosed, affect my application unfavorably. I understand that any misrepresentation or omission of facts on this application could be cause for rejection of this application or dismissal. I understand that after I submit my application, it will be reviewed and my eligibility for volunteer work will be determined. I agree to an interview with the on site manager and to participate in orientation to perform my volunteer role. I hereby release and waive liability against RGA, a non-profit organization, its directors, officers, employees and agents, its successors and assigns, for any injuries or illness that I myself, or my dependent may suffer in connection with any volunteer work for RGA. Further, I agree that RGA is not liable for any damage to my property or my dependent’s property resulting from volunteer work for RGA. I agree that this release is as broad and inclusive as permitted by the laws of the State of Illinois. By typing my name below with the current date, this will count as my volunteer signature.

Date

*If volunteer is under 18 years, the parent or guardian must also sign this volunteer application and agreement form.

Name of Parent or Guardian if Volunteer is under 18 years

Parent / Guardian Address

City

State

Zip Code

Parent / Guardian Home Phone Number

Parent / Guardian Cell Phone Number

Parent / Guardian Email Address

Parent / Guardian Signature

Date