This site is a secure site. Information submitted here is protected from unauthorized use. If you prefer, download the PDF application and submit by email or mail. email@example.com Boys & Girls Clubs of Sheboygan County 107 Cedar Street Sheboygan Falls, WI 53085 Date* Name of Applicant*Address*City*State*ZIP*Home Phone*Cell Phone*E-mail*Current employerOccupationWork addressCityStateZIPBusiness phoneFaxBusiness e-mailPlease list your days and times you are available to volunteer.*How many hours are you committed to volunteer and for what length of time?*Location Preference*SheboyganSheboygan FallsYouth Age Preference*ElementaryTeensWrite a brief statement on why you wish to volunteer at the Boys & Girls Club.*Describe special interests or hobbies that you have (e.g. cooking, crafts, career interests, games, sports, computers, art, languages, music, painting, etc.)*How were you referred to us?*What do you wish to gain from your volunteer experience?*Have you ever been convicted of a crime?*YesNoIf yes, describe the convictions in full.*Have you ever been criminally charged with any crime related to the mistreatment, abuse, or molestation of children?*YesNoIf yes, describe the convictions in full.*CURRENT OR PAST VOLUNTEER EXPERIENCESVolunteer Experience 1AgencyAddressPositionPhoneDatesSupervisorSupervisor e-mailVolunteer Experience 2AgencyAddressPositionPhoneDatesSupervisorSupervisor e-mailVolunteer Experience 3AgencyAddressPositionPhoneDatesSupervisorSupervisor e-mailPROFESSIONAL REFERENCES: NO FRIENDS OR FAMILYReference 1Name*Relationship*Phone*Email*Reference 2Name*Relationship*Phone*Email*Reference 3NameRelationshipPhoneEmailVOLUNTEER RELEASE STATEMENTI, the undersigned, hereby state that if accepted as a volunteer, I agree to abide by the rules and regulations of the Boys & Girls Club (hereafter known as the "Club"). I am not allowed to take the youth off the Club grounds. I have not been convicted, with the past ten years, of any felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state of federally controlled substance. I am not under current indictment. Further, I hereby fully release, discharge and hold harmless the Club, participating organizations and all of their employees, officers, directors, and coordinators from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in volunteering. I understand that the Club staff reserves the right to terminate a volunteer from the program. I give permission for program staff to conduct a criminal background check as part of the screening for entrance into the program. This includes verification of personal and employment references as well as a criminal check with the authorities. Program staff has final right of acceptance of applicant into the program and reserves the right to terminate a volunteer from the program at any time. I have read this Release Statement and agree to the contents. I certify that all statements in this application are true and accurate.Volunteer Signature*Date* Parent Signature (if under age 18)Date RELEASE OF CONFIDENTIAL INFORMATION WAIVERSince one of the fundamental principles of the Boys & Girls Clubs of Sheboygan County is to provide a safe place supervised by adults of good character, our organization conducts background checks of all our volunteers and employees. Please complete the following release form so this check may be done. Thank you for your interest in our organization.Name*I authorize the release of information to the Boys & Girls Clubs of Sheboygan County and its staff. The release includes information gathered from Social Services, law enforcement agencies and/or any source appropriate in determining my qualifications. I understand this information will be kept confidential and will only be used to determine my appropriateness as an employee of the Boys & Girls Clubs of Sheboygan County.Signature*Date* Last Name*First Name*Middle Name*Permanent Address*City*State*Zip*Date of Birth* Social Security Number*List any names you have been otherwise known as:EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.