Volunteer / Intern Application

Contact Information
First Name ___________________________________ Middle Name _____________________________
Last Name ___________________________ Maiden Name (if applicable) __________________________
Date of Birth ______/______/______ Male

Female

Senior Citizen

Veteran

Home Phone _____________________________ Work/Cell Phone ______________________________

Address ____________________________________ City __________________ Zip Code ___________
E-Mail Address ___________________________________________
Emergency Contact
Name __________________________________________________________________
Phone Number ____________________ Relationship to Volunteer _________________
Availability
During which hours are you available for volunteer assignments?
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Am
Pm

Community Service or Internship hours needed _______ Contact / Supervisor: ____________________

(Caseworker, P.O. etc.)
Interests / Programs
Please tell us in which areas you are interested in volunteering
Third Street South

__ Community Events

Bethany Housing

__ Administrative Assistant __Office Support

Muskegon Learning Lab

__Drop-In Lab Assistant __Lab Attendant __Computer updates

Sacred Suds

__Laundry Attendant __Reception

McLaughlin Grows

__Gardening __Gardening Mentor __Site Coordinator

After School Center

__Community Garden __ Catch Camp __ Reading Buddies

Youth Empowerment Project

__After School Program Advisors __ Youth projects

Angell Neighborhood

__Community Garden __Summer Youth Program

__Flyer Distribution __Neighborhood Surveying

__Cleaning

Volunteer Application
Name______________________________________________________

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Related Experience
Have you ever volunteered with any other program(s)? If so, where and what was the activity? Please include
the name and phone number of a contact person.
Activity

Church/Organization Name

Contact Name/Phone #

Advisory/Applicant Statement
Community enCompass reserves the right to perform a criminal background check of volunteer applicants. No
applicant will be denied volunteer service solely on grounds of conviction of a crime. The nature of the offense,
the date of the offense, the surrounding circumstances, and the relevance of the offense to the position will be
considered.
Have you ever been convicted of any crime?

YES

NO

If yes, please describe each conviction, providing dates and circumstances.

________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
I certify that the information contained in this application is correct to the best of my knowledge. I understand
that if any false information, omissions, or misrepresentations are discovered, my application may be rejected
and active volunteer status may be terminated at any time.

Signature _________________________________________________ Date __________________

Photo Release
I hereby give permission to Community enCompass to use images of myself by means of photographs, videos,
or other media for advertising, trade, or any other lawful purposes.
I have read the above release and approve of its terms.
Signature _________________________________________________ Date __________________

CRIMINAL HISTORY DISCLOSURE AND AUTHORIZATION FORM

By providing the information requested, I hereby authorize Community enCompass to conduct a criminal history
background check for the purpose of employment or volunteer services. By providing my information on this form, I
agree that this authorization, in original or copy form, is valid for all current and future criminal background checks
related to my service with Community enCompass and that any information obtained will be used only in connection with
my service to Community enCompass.
Signiture___________________________________________________Date________________________
Contact Information
First Name ___________________________________ Middle Name _____________________________
Last Name ___________________________ Maiden Name (if applicable__________________________
Date of Birth ______/______/______

Gender: _____Male _______Female

Social Security Number _________________________ Race___________________________________

Home Phone _____________________________ Work/Cell Phone ______________________________
Address ____________________________________ City __________________ Zip Code ___________
E-Mail Address ___________________________________________

Have you been convicted of a crime?

_____________________________________________________________________________________

Do you currently have any criminal charges pending?

_____________________________________________________________________________________
Below list the dates, charges or convictions, and in which city, county, and state the charges were filed.
Charges ___________________________________________________ Date ______________________
City / County _______________________________________________ State ______________________
Charges ___________________________________________________ Date ______________________
City / County _______________________________________________ State______________________