Application for Volunteers

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SAVE A LIFE MINISTRIES, INC

Program Volunteer

ApplicationPlease complete and email or mail a copy of this form to:Save A Life Ministries, Inc.

Attn: Project Managerc/o Summers Cottage

1315 S. 3rdSt. Ozark, MO 65721

Phone (417) [email protected]

12/15/2013

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Document is the application for the admission into one of Save A Life Ministries, Inc specificcommunity outreach project programs. All information must be included before application canbe reviewed and processed. Please fill out entirely and return to the above physical or emailaddress. If assistance is needed, please call the phone number listed above.


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Application for Volunteers

Date:____________________

Personal Information

Last Name___________________________ First_________________________ MI_______________

Street Address_________________________________ Home Phone ( )_______-_______________

City, State, Zip_________________________________ Cell Phone ( )________ -_______________

How long at present address? _________ Years ________ Months

What was your previous address?________________________________________________________

How long at previous address? _________ Years ________ Months

Email Address:

Drivers License# State Exp. Date Any Violations? Y / N

Date of Birth ______________________________ Social Security No._______-_____-_______

(2 forms of verification required)

How did you learn of our Ministry?_______________________________________________________

What are your interest?_________________________________________________________________

What area would you like to volunteer within?______________________________________________

What special skills could you teach the girls?_______________________________________________

What is the highest level of education you have completed? ___________________________________

Do you hold a degree and in what?_______________________________________________________

Do you hold any specialized certifications, ie first aid, CPR, etc?________________________________

____________________________________________________________________________________

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____________________________________________________________________________________

Are you married? Y / N If so, how long? ___________________ If not, were you ever? Y / N

Do you have children? Y / N If yes, how many and how old are they?_________________________

___________________________________________________________________________________

Does your family have a religious preference? Y / N If so, are you a member or do you attend

church and where? ____________________________________________________________________

Are you involved in any other ministry or have you ever volunteered anywhere else? Y / N If yes,

please provide the name, a contact person and a phone number._________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Has anyone in your immediate family ever been involved with a recovery program of any kind? Y / N

If so, what kind and where? ____________________________________________________________

Have you ever been diagnosed with any type of disease requiring continued medical treatment and/or

medication? Y / N If so, explain______________________________________________________

__________________________________________________________________________________

Are you currently taking any medications? Y / N If yes, explain_____________________________

__________________________________________________________________________________

Do you have any allergies? Y / N If yes, explain__________________________________________

___________________________________________________________________________________

Do you smoke? Y / N If yes, how much and how long have you been smoking? ________________

___________________________________________________________________________________

Do you drink alcohol? Y / N If yes, how much and how often? ______________________________

___________________________________________________________________________________

Do you or have you ever used illegal drugs, prescriptions that do not belong to you or over the counter

medications in a way they were not intended? Y / N If yes, what, how much and how often? ______

___________________________________________________________________________________

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___________________________________________________________________________________

Have you ever experienced depression? Y / N If yes, have you ever thought about or attempted

suicide? Y / N If yes, how and when?__________________________________________________

__________________________________________________________________________________

Do you now or have you ever struggled with an eating disorder or any form of self-mutilation? Y / N

If yes, what type and how long ago?______________________________________________________

Are there any other reasons for which you might not be able to perform the job and/or household duties

(with a reasonable accommodation)? Y / N If Yes, please explain.___________________________

____________________________________________________________________________________

Are you legally eligible for employment in the United States? Y / N

Are you employed now? Y / N If so, may we inquire of your present employer? Y / N

Are you involved in any civil cases involving DFS or any other government agency? Y / N

If yes, explain and list any case workers___________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

Have you been convicted of a crime, including misdemeanors and summary offenses, which has not

been annulled, expunged or sealed by a court? Y / N If Yes, describe in full.___________________

___________________________________________________________________________________

____________________________________________________________________________________

Employment History Please give accurate, complete full-time and part-time employment record. Start

with present or most recent employer.

1. Company Name ___________________________________ Telephone ( ) _____ - _______

Address ___________________________________________ Employed From ______ To ______

Name of Supervisor__________________________________ Hourly Rate __________________

Job Title and Duty Description:_________________________________________________________

Describe Your Work Reason for Leaving__________________________________________________

___________________________________________________________________________________

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___________________________________________________________________________________






___________________________________________________________________________________

References: Give below the names of five persons not related to you, whom you have known at

least one year (At least one should be a pastor or professional with whom you have worked).

Name Phone # Relationship Years Acquainted

1.__________________________________________________________________________________

2.__________________________________________________________________________________

3.__________________________________________________________________________________

4.__________________________________________________________________________________

5.__________________________________________________________________________________

The information provided in this Application for a Program Volunteer position, is true, correct and

complete. Any misstatements or omissions of fact on this application may result in my rejection and

dismissal. I understand that acceptance into Save A Life Ministries, Inc program does not create a

contractual obligation upon the ministry to continue to assist me or utilize my services in the future.

Furthermore, I understand that Save A Life Ministries, Inc is a mandated reported and any information

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collected from myself or by me from a third party, that is in violation with state or federal law must be

reported. I also understand that failure to report said violations can terminate any future volunteering

eligibility. Upon acceptance into the volunteer program, I agree to maintain all the confidentiality,

ethical, legal, state, federal and household rules to the best of my ability and will not hold Save A Life

Ministries, Inc legally responsible for any civil matters that might arise in the course of volunteering.

If you decide to engage an investigative consumer reporting agency to report on my credit and a

background check of my personal history, I authorize you to do so. If a negative report is obtained

interfering with my acceptance as a volunteer, you must provide, at my request, the name and address of

the agency so I may obtain from them the nature and substance of the information contained in the

report.

___________________ ______________________________________________________________________________Date Signature

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Application for Volunteers

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