ATTN: PLEASE COPY AND PASTE THE INFORMATION BELOW AND EMAIL OR FAX TO KELLIE GLENN.
For Covenant House Use Only: Please Return Completed Application To:
Last Name_________ Kaylah Walker, Kwalker@covenanthouse.org
Date Received:___________________ (Fax) 404-832-1282
Instructions: Please read carefully and print the information clearly. You may email or fax the form back, but you will need to provide an original one with your signature at orientation.
I am applying as a: Volunteer___ Intern___
(You are an intern if you are fulfilling a requirement with your school.)
Personal Contact Information:
Last Name:______________________ First Name:____________________ Middle Initial:___
Home Phone:_______________Mobile Phone:______________Email:___________________
Occupation:______________________________Company or School_____________________
___ Please check if you are 18 years or younger. Volunteers/Interns under the age of 18 may not work directly with the residents.
Highest Level of Education Completed: _______________________________________________
Have you ever been arrested or charged with a felony? (Excludes minor traffic violations)
___ No ___ Yes (If yes, Please explain :________________________________________________)
Have you ever been convicted of child abuse and maltreatment?
___No ___Yes (If yes, Please explain :__________________________________________________)
Do you have any previous volunteer experience? Briefly describe-indicating organization name, time of involvement, duties, and population served. __________________________________________________________________________________________________________________________________________________________________________
List any special training/skills or hobbies you have (i.e. foreign language, arts and crafts, computers, tutoring, etc.) __________________________________________________________________________________________________________________________________________________________________________
Please indicate the times you can commit to on: (Indicate AM or PM)
If you are an INTERN: How many hours do you need to fulfill per semester? _________
How many hours do you need to fulfill per week? ________
In case of Emergency Notify:________________________________Phone:________________
References: Please list two individuals who have known you for at least two years. (You may not use relatives or significant others). Covenant House Georgia reserves the right to contact your references.
Please read carefully and sign. Without your signature the application is not valid.
Covenant House Georgia matches interested volunteers/interns based on the needs of the agency and the specification of the potential volunteers/interns interests.
I understand it is my responsibility to ensure that the agency receives any necessary information that would aid the assessment process and non-compliance will result in withdrawal of my consideration as a volunteer/intern for Covenant House Georgia.
I understand and acknowledge that I am applying to volunteer my time and services to Covenant House Georgia and that if my application is accepted as a “volunteer,” I will receive no compensation from Covenant House Georgia for my time and services.
My signature on this form does not obligate me to perform volunteer services applied for, and the agency is not obligated to assign, or actively seek to assign my placement.
I acknowledge that this application becomes property of Covenant House Georgia. All of the information I provide is accurate and true and is subject to verification by Covenant House Georgia. No information has been withheld, which would affect my application unfavorable before or during my time of volunteer/internship service. In the event of the agency’s determination of my ineligibility, in accordance with longstanding agency policy, the reason will not be provided.
Please note: Covenant House Georgia does not discriminate with regards to applicant’s race, color, creed, gender, sexual orientation, marital status, place of national origin, age, or disability.
Applicant Name :_________________________(please print)
Applicant Signature: ___________________________________ Date:______________________
Covenant House Georgia Volunteer Agreement and Consent Form
Please print your full name as indicated below and sign this agreement authorizing a criminal records check and your acceptance of the terms of this agreement.
In consideration of the opportunity to do volunteer work with Covenant House Georgia, I agree to the following:
I____________________________ (Print Full Name) hereby authorize Covenant House Georgia, in accordance with all state and federal laws, to search, review and receive any criminal history information pertaining to me, including information as to my personal character, mode of living, general reputation, and other qualities pertinent to my service. I understand that Covenant House will use Sterling InfoSystems, Inc. to obtain a consumer report and/or investigate consumer report as part of the volunteer process.
I recognize Covenant House Georgia to terminate, without notification as to the reason for termination, the services of any volunteer at any time.
I authorize without reservation, any party (including, but not limited to, law enforcement agencies, state agencies, and private information bureaus or repositories) contacted by CHGA and/or Sterling InfoSystems, Inc to furnish any or all of the above mentioned information. In addition, I hereby release Sterling InfoSystems, Inc and CHGA from any and all liability for damages arising from investigation and disclosure of the requested information. I further release and discharge all liability from all companies, agencies, officials, officers, employees and other persons, who, in good faith, provide to CHGA and/or Sterling InfoSystems, Inc the above mentioned information as requested, in order to successfully complete a background investigation for my request for volunteer service. I will allow a photocopy of this authorization to be as valid as the original for purposes as determined necessary by CHGA and/or Sterling InfoSystems, Inc.
Print Full Name________________________________________________________________________
Social Security Number__________-__________-_________ *Date of Birth________________________
City_______________________________ State________________Zip Code_______________________
Driver’s Lisence Number_________________________ State____ *Sex_____ * Race_________
Have you resided in Georgia for Seven Years?__________________
If no, please list the cities and states you have resided in for the past seven (7) years?
City ______________________________ State___________
Non-Profit Organization: Covenant House Georgia
2488 Lakewood Avenue, SW
Atlanta, GA 30315
Phone: (404) 658-9405
Fax: (404) 832-1282
*Date of Birth, Sex, and Race are being requested only for the purpose of identification in obtaining accurate retrieval of records, and will not be used for discriminatory purposes.
Volunteer Confidentially Statement
I, the undersigned, understand that any information, which is disclosed to me while I am visiting Covenant House Georgia, is confidential and that this confidentially is protected by federal law. I understand that I cannot make any disclosure of this protected information without the written permission of the residents.
Printed Name of Volunteer___________________________________
Signature of Volunteer______________________________________
Covenant House Georgia Background Check and Registration Information
Please contact the Atlanta Police Department or your local police department about conducting your background check. Please note the Cost is $10.00 and they only take cash or money order.
Atlanta Police Department
3493 Donald Lee Hollowell PKWY, NW
Atlanta, Georgia 30331
Once application and background check are completed, please register with Kellie Glenn at Kglenn@covenanthouse.org for Volunteer Orientation. Please bring completed application packet with you to orientation.
Covenant House Georgia Volunteer Orientation Schedule 2011-2012 - Please call Kellie directly for a schedule.