Volunteer Application

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Applicant

First Name *

Last Name *

Preferred name

Birth Date *

Month

Day

Year

Gender *

Cell Phone *

Email *

Best time to contact *

Address: Street Address *

Address: Line 2

Address: City *

Address: State *

Address: Zip Code *

Where would you prefer to volunteer? *

Manatee County

Sarasota County

Place of Employment

Job Title or Occupation *

Emergency Contact Name *

Emergency Contact Cell Phone *

UnidosNow organizes many volunteer/ mentor programs serving children and vulnerable populations. Because we work with a variety of child-care agencies, some which are government related, we must ask you to please provide the following information. Please answer this section with yes or no.

Assertions

Have you ever been convicted of a felony, violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or sexual offense, or even been ordered by a court to receive psychiatric or psychological treatment in connection therein? *

Yes

Are you the subject of a report of child abuse or maltreatment of a child or an adult on file in any state? *

Yes

Are you a registered sexual offender/predator? *

Yes

Have you been terminated, suspended, placed on probation, reprimanded, or otherwise penalized by an employer for child abuse or maltreatment of a child or an adult in this state or elsewhere? *

Yes

I declare that all statements I have made in this screening summary are true, correct and complete to the best of my knowledge.

Signature date

Month

Day

Year

Signature *

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