LANCASTER NH

COLONEL TOWN RECREATION

VOLUNTEER APPLICATION FORM

ALL INFORMATION PROVIDED WILL BE CONFIDENTIAL

Name                                                                      Social Security #_____-____-_____                                                

Mailing Address:  ____________________________________________________                                                                                                                                  

Home Address (if different):  ____________________________________________                                                                                                                  

Phone/Contact Information:

                Day:  (____)             -                            Best time to call:                          a.m./p.m.

         Evening:  (____)             -                            Best time to call:                          a.m./p.m.

                Cell:  (____)             -                            Best time to call:                          a.m./p.m.

   Email:                                                                          FAX:  (____) ______ - ________

Address(es) for previous 5 years (listing most recent to oldest):

1.      ____________________________________________________________

2.      ____________________________________________________________

3.      ____________________________________________________________

Name(s) previously used (including maiden name):

1.      _____________________________

2.      _____________________________

Current Employer’s Name and Address:  ____________________________________________

                                                                   ____________________________________________

                                                                   ____________________________________________

                                                                   ____________________________________________

1.  Please describe your:

• Current Occupation -

• Special Skills and Training -

• Previous Work with Youth -

• Previous Volunteer Experience -

2.         What type of position(s) do you prefer?

                              Coach                                           _     Activity/Event Leader

                              Referee/Umpire                                  Snack Bar Helper

                           _ Camp Volunteer                                  other (specify) ____________________

3.         With which age group(s) do you prefer to work?

      Preschool                                            Grades 7-12

                              Grades K-2                                         Adult Mix

                           _ Grades 3-4                                          Seniors

4.         If you want to coach, referee, umpire, or teach a sport, which sport(s) do you prefer?

                               Baseball                                              Gymnastics

                   Basketball                                           Soccer

                   Cheerleading                                       Softball

                   Dance                                                 Weight Lifting

            ___ Flag Football                                ___ other (specify)____________________

5.         Briefly explain why you would like to be a Colonel Town volunteer.

6.         Any additional information you would like us to know.

Colonel Town has a responsibility to provide a safe and healthy environment for all youth. 

Because of this responsibility, we ask for the following information.

If you answer "yes" to any of the questions, please explain below.

a.         Do you use illegal drugs?                                                                   Yes   _             No   __

b.         Have you ever been convicted of, pled nolo contendred to,

            or received a deferred or suspended sentence for a crime

            more serious than a parking offense in this or any other

            state, territory or country?                                                                   Yes ___           No ___

Please explain any "yes" answers here:

7.         References

Please list 4 people who have known you for at least 2 years. They should be familiar with your character as it relates to working with young people.  Please do not include family members.  Each may be asked by phone or by letter to complete a short questionnaire.  All responses will be held confidential.

PLEASE INCLUDE COMPLETE ADDRESSES AND PHONE NUMBERS.

Colonel Town has a responsibility to provide a safe and healthy environment for all youth and reserves the right to complete a background check on applicants.  Persons with a history of violent behavior, child, or current drug/alcohol abuse need not apply.

I certify that the information supplied on this application is the truth.  It is understood and agreed that any misrepresentation by me on this application and accompanying resume or interviews will be sufficient cause for cancellation of this application and/or termination from the Colonel Town Recreation program.  I authorize Colonel Town to investigate all information provided and to secure additional information about me for personnel decisions.  I freely release from liability Colonel Town and its representatives for seeking such information and all other persons, schools, corporations, or organizations for furnishing such information.

I have read and understand the above.

Volunteer Signature:  ___________________________________           Date:  ____/____/____

Colonel Town Signature:  ________________________________          Date:  ____/____/____

Colonel Town Recreation is an equal opportunity educator and employer.

“It’s Not Me. It’s Not You. It’s Us!!”  Lou Leaver                                           Revised:  9/26/02