Information Last Name First Name M.I. Address Apt/Unit # City State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Phone Email Date Available Social Security No Date of Birth I am interested in helping with Have you lived outside of Iowa in the past seven years? YesNo If so, please list all other states you have lived in the past seven years Are you on the Sex-Offender Registry? YesNo Do you have a valid driver's license? YesNo Have you ever been convicted of a crime, pled guilty, or been given a deferred judgment? YesNo If yes, please explain Are you interested in short-term or long-term volunteering opportunities? Short-TermLong-Term Have you applied to other mentoring organizations? YesNo If you have mentored elsewhere, where? Are you or have you been a Foster Parent? Have you ever applied? If so, please give a DHS reference contact. Education/Interest High School Address From To Did you graduate? YesNo Diploma College Address From To Did you graduate? YesNo Degree I am interested in volunteering in the following areas: Mentoring tutor - Meet 1:1 with student 4 hours/month commitment. Min 18 mos. YesNo Marketing, technology, or interpreting volunteer YesNo Finance, fundraising, or education committee YesNo Occasional volunteer - helps with large group events as schedule allows YesNo Other, please describe References Please list three personal references. Full Name Relationship/Yrs Known Company Phone Address Full Name Relationship/Yrs Known Company Phone Address Full Name Relationship/Yrs Known Company Phone Address Previous Volunteerism References Place of Activity Phone Address Supervisor Job Title/Responsibilities From To Reason for Leaving May we contact your previous place(s) of volunteerism for a reference check? YesNo Place of Activity Phone Address Supervisor Job Title/Responsibilities From To Reason for Leaving May we contact your previous place(s) of volunteerism for a reference check? YesNo Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment or volunteer work, I understand that false or misleading information in my application or interview may result in my termination. I do hereby give consent for The Job Foundation to contact all references I have listed in this document and for The Job Foundation to question each reference thoroughly to their satisfaction. I understand and agree that I may not receive any information regarding what was shared with The Job Foundation during their screening process of me included but not limited to: criminal background checks, personal references, and volunteerism references. Also, I do hereby give consent for The Job Foundation to conduct criminal background and department of human services checks on me. In case you are with us or at the school volunteering and have an emergency, whom should we contact? Name of Emergency Contact Phone Number I give my permission that The Job Foundation may use my photograph for marketing, public relations, or for the growth of the program on social media, letters, mailings, or other media. The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.