<p> Center for Service and Civic Engagement</p><p>Champlain College - Skiff Annex</p><p>(802) 917-3799</p><p> [email protected]</p><p>Volunteer Background</p><p>Name: ______Date: ______</p><p>Date of Birth: ____/____/____ Gender: ______</p><p>Major: ______Year of Graduation: ______</p><p>Phone: (____) ____ - ______Email: ______</p><p>Residence Hall (if applicable): ______</p><p>Burlington Address: ______</p><p>Do you have an independent form of transportation: ______</p><p>In case of Emergency:</p><p>Name: ______</p><p>Relationship: ______Phone: (____) ____ - ______</p><p>Do you know anyone that you think would make a great mentor? Recommend them!</p><p>Full name: ______Email: ______</p><p>Volunteer Interest</p><p>Circle program(s) you’d like to volunteer with:</p><p>Active Based Learning | Lunch Buddies | Lunch Mentors | Playground Pals</p><p>| Studying Toward English Proficiency (STEP) | Music Masters | </p><p>Outdoor World Learning | To The Top Tutoring | Word Play | Magic Club | Young DJs Circle Day(s) Available: </p><p>Monday | Tuesday | Wednesday | Thursday | Friday</p><p>Why do you want to volunteer with AIM? ______</p><p>______</p><p>______</p><p>______</p><p>What experience do you have that would help you in volunteering with AIM? ______</p><p>______</p><p>______</p><p>______</p><p>Fill this space with anything you want. This section is required, but writing is not.</p><p>Background Information</p><p>Have you ever been convicted of a crime? (If yes, please explain.)</p><p>______</p><p>Do you now, or have you ever, had a drinking or drug problem? ______</p><p>Our volunteer screening process consists of a check of two references of your choosing, and interview conducted by one of the coordinators. Your references should be able to speak to the quality of your character and if you have had any prior experience working with children. (Please do NOT list relatives)</p><p>Reference #1: Reference #2:</p><p>Name: ______Name: ______</p><p>Relation/Title: ______Relation/Title: ______</p><p>Phone: (____) ____ - ______OR Phone: (____) ____ - ______OR Email: ______Email: ______</p><p>Photo Consent</p><p>I hereby irrevocably give my consent to the Center for Service and Civic Engagement and to such other persons as they may designate, to use my name, verbal statements and portrait or picture (motion or still) for public relations, advertising purposes, or for any lawful purpose whatsoever, in any media now known or hereafter developed. My signature on this form means I have read this paragraph or had it explained to me in a language I can understand.</p><p>Applicant Signature: ______Date: ____/____/_____</p><p>I do not give permission to the Center for Service and Civic Engagement to have photographs or audio/video recordings of myself.</p><p>Applicant Signature: ______Date: ____/____/_____</p><p>Volunteer Expectations As a volunteer for AIM, I agree to the following:</p><p>• To attend a training session before beginning. • To be on time for scheduled meetings and sessions. • To notify AIM program coordinator I am unable to keep my weekly volunteer time. • To notify AIM program coordinator of changes in my email address and phone number. • To engage in the AIM program with an open mind. • To accept assistance from school teachers, staff, and AIM program coordinators. • To report information of abuse to the guidance counselor. • To ask for assistance when help is needed. • To participate in a mid-semester program evaluation and end-of-semester reflection.</p><p>Applicant Signature: ______Date: ____/____/_____</p>