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420 South Maple Avenue, Falls Church VA 22046 (City of Falls Church)

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BROWSE CITY OF FALLS CHURCH (VA) FORMS

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AURORA HOUSE CONFIDENTIAL APPLICATION FOR VOLUNTEERS
420 South Maple Avenue, Falls Church VA 22046
703-237-6622 (TTY 711) 703-237-6624 (FAX) aurora_house@fallschurchva.gov
IDENTIFYING INFORMATION
NAME
DATE OF BIRTH
COMPLETE ADDRESS (Street, City, Zip Code)
SOCIAL SECURITY #
EMAIL ADDRESS
DRIVER’S LICENSE #
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
EMPLOYMENT INFORMATION
CURRENT EMPLOYER
OCCUPATION
COMPLETE ADDRESS (Street, City, Zip Code)
EDUCATION
HIGHEST LEVEL OF EDUCATION COMPLETED ☐ High School ☐ Associate’s ☐ Bachelor’s ☐ Graduate
Please check the area(s) you would like to volunteer at Aurora House.
☐ Tutoring House Maintenance ☐ Clerical
☐ Gardening ☐ Recreational ☐ Arts & Crafts
☐ Computer Skills ☐ Other: ☐ Baking/Cooking
Please describe any special skills, training, interests, or hobbies that you feel would be helpful in your
volunteering at Aurora house.
If you have preferred days and hours you would like to volunteer at Aurora House, please indicate below.
Previous or present volunteer positions:
Please list the names and contact information of four persons who can provide personal references and who have known
you for at least two years. INCLUDE EMPLOYER. Please do not use relatives. Please provide all the information
requested below; we will contact each person listed before final approval is determined.
NAME
YEARS KNOWN
RELATIONSHIP TO YOU
COMPLETE ADDRESS (Street, City, Zip Code)
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
EMPLOYER
NAME
YEARS KNOWN
RELATIONSHIP TO YOU
COMPLETE ADDRESS (Street, City, Zip Code)
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
EMPLOYER
NAME
YEARS KNOWN
RELATIONSHIP TO YOU
COMPLETE ADDRESS (Street, City, Zip Code)
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
EMPLOYER
NAME
YEARS KNOWN
RELATIONSHIP TO YOU
COMPLETE ADDRESS (Street, City, Zip Code)
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
EMPLOYER
THE UNDERSIGNED ACKNOWLEDGES AND AGREES THAT:
1. He/she is not obligated if called upon to perform the volunteer services herein applied for, and that Aurora House is
not obligated to assign or actively seek to assign him/her to an adolescent.
2. That as a part of Aurora House’s volunteer approval process, a background check, fingerprint cards, and Child
Protective Services check will be completed and if needed we may ask for additional personal information from the
applicant; and
3. The Aurora House Director reserves the right at all times to terminate any match between any Volunteer and Client for
whatever cause.
I hereby affirm that the information given is true and accurate to the best of my knowledge and belief and that I have not
withheld any facts or circumstances that would, if disclosed, affect my application unfavorably.
Signature: _________________________________________ Date: ________________________
(please print form and sign)
AURORA HOUSE
Revised 2/12/16
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420 South Maple Avenue, Falls Church VA 22046 (City of Falls Church)

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Completed 3 August 2020

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