GREAT MIAMI VALLEY
VOLUNTEER APPLICATION & AGREEMENT

Date: Name*: Preferred Method of Contact:

Home #: Work #: Cell: Email*:

City*: State*: Zip: Date of Birth*: (If under 18 years of age, a parental/ guardian signature is required on second page.)

How long at above address? If less than 5 yrs. current address, please list prior addresses:

Address City State Zip How long?

Address City State Zip How long?

1. What is your occupation? (Be Specific)

Place of Employment?

Address City State Zip How long?

2. Describe any formal/informal traning you may have had as a coach or volunteer (Coaching Clinic, Courses, P.E. Degree, etc):

3. Have you ever pleaded no contest, guilty or been convicted of a criminal offense?

I acknowledge and accept that as a volunteer for the YMCA, may be subject to background check, Including criminal history. (We are required by Ohio Revised Code to inform you that we may require fingerprinting and a criminal record check on any volunteers who have unsupervised access to a child.) Please initial here*:

4. Explain why you are interested in volunteering:

NAME & HOME ADDRESS	FIRM/ NAME/ADDRESS IF APPLICABLE	PHONE NUMBERS	KNOW IN WHAT CAPACITY?(Friend, Pastor, etc)	HOW LONG KNOWN?
		DAY: EVE:
		DAY: EVE:
		DAY: EVE:

I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by the YMCA. I authorize the schools, persons, previous employers, agencies and other organizations named in this application to provide the YMCA (its authorized employees, agents or representatives) with any relevant information that may be required to arrive at a volunteer placement decision and hereby release any such schools, persons, employers, agencies and organizations from any and all liability which they might otherwise incur as a result. I understand that any misrepresentations or omission of a material fact on my application may be justification for refusal for placement.

I hereby give my permission for the YMCA to obtain information relating to my criminal history record. I understand that this information will be used to determine my eligibility for a volunteer position with this organization.

I also understand that as long as I remain a volunteer here, they may repeat this criminal history check at any time.

In the event I volunteer, I understand that all volunteers are subject to dismissal at the discretion of the YMCA. If, in the event I choose to cease volunteering, I am free to do so at any time. I also understand that, if selected to volunteer, any misrepresentation made by me completing this application shall be considered as sufficient cause for my dismissal without advanced notice.

In the event of my selection, I will comply with all rules and regulations as set forth by the YMCA. I have read, understand and support the YMCA's position on the problem of child abuse.

I understand that completion of this form does not guarantee me status as a volunteer. I must meet all stated conditions required of the position for which I am asking to be considered.

I have read the above statement and accept the same as a condition of my placement with the YMCA.

Signature of Applicant*: Date:

Signature of Parent / Guardian if under the age of 18 years Choose one: Parent Guardian

The YMCA does not discriminate in the recruitment and placement of volunteers on the basis of race, color, religion, national origin, sex, marital status, disability, age or veteran status.

No question on this application is intended to secure information to be used in a discriminatory manner. Volunteer consideration necessitates that you meet all conditions required for the position for which you are applying.