Employer Telephone #
Street Address
Position Held
Immediate supervisor and title (for most recent position held)
Dates Employed: __________ to ______________
Summarize the type of work performed
May we contact for reference? If so, provide an
email address.
Current Employer Information (If not applicable, write N/A)
Volunteer Application
Equal access to programs, services, and volunteering is available to all persons. Applicants requiring
reasonable accommodation to the application and/or interview process should notify the supervisor for the
volunteer position.
Position(s) applied for_________________________________________Date of application (MM/DD/YYYY)_________________
Name (Last/First/Middle)______________________________________________________________________________________
Address (Street/City/State/Zip)_________________________________________________________________________________
Cell Phone # __________________________________________ Email ___________________________________________
Emergency Contact Person (Name and phone number): _________________________________________________________
Referral Source (How did you hear about this opportunity?)_________________________________________________________
Driver’s License number: (Required if driving is required in the job for which you are applying: ________________ State: _______
Name of Auto Insurance Company___________________________________________________________________________
Answering “yes,” to either part of the following question does not constitute an automatic bar to volunteering. Factors such
as date of the offense, seriousness and nature of the violation, what victims were involved, rehabilitation, and position applied
for will be taken into account. Please note that all offers of volunteer positions are contingent upon an applicant passing a
criminal background check and a consumer investigative report. Some applicants may also be required to pass a Child
Abuse and Neglect background check, as reported by MO Dept. of Social Services or other child protective services organiza-
tions, as a condition of working with children.
Has your license ever been suspended, or have you ever pleaded “guilty” or “no contest” to, or been convicted of, a crime?
If yes, please provide date(s) and details:
List any special training, skills, licenses, awards, and/or certificates that may assist you in performing the position for
which you are applying:
Description Year Awarded/Granted/Received
(if applicable)
Granting Organization (if applicable)
Starting with your most recent school attended, provide the following information.
School (include city/state) Years
Completed GPA
Class Rank
What would you like to get out of volunteering here?
Would you feel uncomfortable working with victims of sexual abuse, child sexual abuse, rape, homicide, DWI, assault, robbery,
domestic violence, child physical abuse, human trafficking, male victims, or those who are developmentally disabled? If yes to any
of these classifications, please explain:__________________________________________________________________________
Have you ever volunteered with us before? If yes, give dates and position: _____________________________________________
Have you ever volunteered elsewhere? If yes, give dates and positions:
I certify that all information I have provided is true, complete, and correct.
I expressly authorize, without reservation, the organization, its representatives, employees or agents to contact and obtain
information from all references (personal and professional), employers, public agencies, licensing authorities and educa-
tional institutions and to otherwise verify the accuracy of all information provided by me in this application. I hereby
waive any and all rights and claims I may have regarding the organization, its agents, employees or representatives, for
seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the interview and back-
ground check process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard
from the organization and still wish to be considered for a position, it may be necessary for me to reapply and fill out a
new application.
If I am selected as a volunteer, I understand that I am free to resign at any time, with or without cause and with or with-
out prior notice, and the organization reserves the same right to terminate me any time, with or without cause and with or
without prior notice. This application does not constitute an agreement or contract for any specified period or definite
duration. I understand that no supervisor or representative of the organization is authorized to make any assurances to the
contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they
are in writing and signed by the employer’s Executive Director.
I also understand that if I am selected, I will be required to provide proof of identity. This Company does not tolerate
unlawful discrimination in its volunteer practices. No question on this application is used for the purpose of limiting or
excluding an applicant from consideration on the basis of race, color, ancestry, national origin, gender, sexual orienta-
tion, marital status, religion, age, disability, gender identity, results of genetic testing, or service in the military, or any
other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment
based on sex, sexual orientation, gender identity, race, color, religion, national origin, genetic information, citizenship,
age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all com-
plaints will be investigated promptly and thoroughly.
I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect,
will be sufficient cause to (i) eliminate me from further consideration for a volunteer position, or (ii) may result in my
immediate discharge from the organization’s service, whenever it is discovered.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. I hereby
release The Victim Center from any liability resulting from my actions while serving as a volunteer for the or-
Signature of Applicant________________________________________Date (MM/DD/YYYY)__________________
Form updated 04/19/2019
List names and telephone numbers of two professional and one personal reference.
NAME Title Relationship
to You
Telephone Email # Years
click to sign
click to edit