Mid-Columbia Children S Council, Inc

MID-COLUMBIA CHILDREN’S COUNCIL, INC. 1100 E. MARINA WAY, SUITE 215, HOOD RIVER, OR 97031 (541)386-2010 FAX (541)386-4597 www.mcccheadstart.org VOLUNTEER APPLICATION MCCC is an equal opportunity provider

PERSONAL INFORMATION

NAME DATE

MAILING ADDRESS

PHYSICAL ADDRESS

PHONE NUMBER CELL PHONE

ARE YOU 15 YEARS OR OLDER? Yes No DATE OF BIRTH

IN CASE OF EMERGENCY NOTIFY PHONE

VOLUNTEER PREFERNCE

1.) WHICH AGE GROUP WOULD YOU PREFER TO SPEND TIME WITH? 0-3 yrs  3-5 yrs  Either 

2.) SELECT SCHEDULE PREFERENCE :

Mon  Tues  Wed  Thurs  9:30 – 11:30 AM  1:30 – 3:30 PM 

3.) CENTER(S) REQUESTING TO VOLUNTEER: Country Club  Belmont  Parkdale  The Dalles 

Wahtonka  White Salmon  Petersburg  Madras  Maupin  Stevenson  Goldendale  Klickitat 

Central Office  GENERAL INFORMATION

SUBJECT OF SPECIAL STUDY, CERTIFICATIONS AND/OR ACCREDIATIONS

SPECIAL SKILLS

ARE YOU BILINGUAL? Yes No WHICH LANGUAGE(S)? SPECIFIC VOLUNTEER EXPERIENCES

WHICH AREAS WOULD YOU BE MOST INTERESTED IN SPENDING YOUR VOLUNTEER TIME (i.e. CLASSROOM READING, FIELD TRIPS, ART, OFFICE/CLERICAL ASSISTANCE)

WHERE DID YOU HEAR ABOUT THIS VOLUNTEER OPPORTUNITY?

CRIMINAL INFORMATIION 0e802f99d9c0ef109f3c76fa9e0b8f42.doc 1 Revised: 4/28/2018 Offenses 1. All pending and prior criminal arrests and charges related to child sexual abuse and their disposition 2. Convictions related to other forms of child abuse and/or neglect 3. All convictions of violent felonies

Have you ever been convicted of any crime (Felony or Misdemeanor)? Yes No Have you even been arrested or cited for a crime that has not been resolved, or are you in a diversion program? Yes No If yes, list any and all pending or prior convictions related to any form of child abuse or neglect, and list any violent felonies:

The declaration may exclude: 1. Any offense, other than any offenses related to child abuse and/or child sexual abuse or violent felonies committed before the prospective employee’s 18th birthday, which was finally adjudicated in a juvenile court or under a youth offender law 2. Any conviction for which the record has been expunged under federal or state law 3. Any conviction set aside under the federal youth corrections act or similar state authority

Please provide your signature on the appropriate item below:  I have not been arrested, charged and/or convicted on one or more of the types of offenses listed above.

______Signature Date

 I have been arrested, charged and/or convicted on one or more of the types of offenses listed above.

______Signature Date

*Please list the offense(s), date(s) or the arrest(s), charge(s) and/or conviction(s) and other relevant information.

Note: Individuals, who declare, through this form, that they have been arrested, charged with or convicted of any of the offenses listed, are not automatically disqualified. Head Start agencies must review each case to assess the relevance of an arrest, charge or conviction prior to volunteer assignment.

I certify that the facts contained in this application are true and complete to the best of my knowledge. Federal Law requires that we, the employer, does a criminal background check on prospective volunteers. I understand and agree to this background check and all other contingencies required for this position.

Applicant Name (Print) Applicant Signature Date

0e802f99d9c0ef109f3c76fa9e0b8f42.doc 2 Revised: 4/28/2018