Badger-Hawkeye Region 4860 Sheboygan Avenue Madison WI 53705

Transcription

1 AMERICAN RED CROSS Badger-Hawkeye Region 4860 Sheboygan Avenue Madison WI VOLUNTEER APPLICATION First name: Middle initial: Last name: Preferred name, if different from above: Street Address: Apt: City: County: State: Zip: Ho me Phone: Cell phone: Employer: Occupation: If retired, please list your most recent employer: EMERGENCY CONTACT INFORMATION Name: Relationship: City: County: State: Zip: Daytime Phone: Evening Phone: HOW DID YOU HEAR ABOUT THE RED CROSS VOLUNTEER PROGRAM? (Please circle all that apply) Blood Donation Red Cross course Organizational Referral Radio/TV Disaster Response Walk-In School Employee Referral Direct Mail Volunteer Referral Newspaper Article Volunteer Match Poster Red Cross Newsletter Volunteer Information Session Website Volunteer Fair Other: WHAT IS YOUR MOTIVATION TO VOLUNTEER WITH THE AMERICAN RED CROSS? Internship School-Service Learning Project Career Experience School Credit Social Benefit Re-entry into Job Market Other: Are you required to serve volunteer hours as part of a court ordered service agreement? Yes? No? If yes, how many hours? Agency:

2 BACKGROUND AND SKILLS Do you have previous American Red Cross volunteer experience? Yes? No? If yes, Where? How long did you volunteer? Position? Have you ever been employed by the American Red Cross? Yes? No? Location: Title: Department: Dates: Do you currently hold any Red Cross certification (e.g., Health & Safety instructor, DSHR member, CPR)? Please List: Education: Please list any special skills, hobbies or interests that might be helpful in your volunteer work: Please describe any language skills you may have: Are you comfortable using a computer? AVAILABILITY What days of the week and times are you available to volunteer? Long Term? Short Term? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Does your schedule change with the seasons or the school year? Please explain: VOLUNTEER OPPORTUNITES Please check all areas that interest you. We'll provide additional information during your initial interview. Training requirements vary, as do positions available. BLOOD SERVICES EMERCENCY SERVICES? Donor Room West? Donor Room East Train to be of help to others in their time of greatest need Near Hilldale Mall Near East Towne Mall? Disaster Action Team Members Monday Saturday Tuesday - Saturday HEALTH AND SAFETY SERVICES? Local Community Blood Drives Equip our community with lifesaving skills Times and locations will vary? CPR / First Aid / AED Instructors? Babysitting Instructors? Drivers Transport blood products throughout region OFFICE SUPPORT Provide volunteer shuttles Lend your skills to provide strong customer service? Computer Records Mgt and Data Entry? Ambassadors / Recruiters? Phone Assistance Work with various departments to promote? Office Partners tasks will vary the value of blood donation? Bi-Lingual Communications support Provide support at local health fairs

3 VOLUNTEER EXPERIENCE Organization: Phone #: Job Title: Dates: From To VOLUNTEER EXPERIENCE Organization: Phone #: Job Title: Dates: From To REFERENCES Please provide complete mailing information for one personal and one professional reference. If possible, please include a present or past employer. Name: Relationship: City: State: ZIP: (Area Code) Telephone Number: Name: Relationship: City: State: ZIP: (Area Code) Telephone Number: CONSENT FOR RELEASE OF BACKGROUND INFORMATION I certify that the information in this application is correct to the best of my knowledge and belief. I authorize the American Red Cross to check the references I have provided and check with the appropriate public authorities regarding my background and history. I understand that, should I be offered a volunteer position, any misrepresentation by me may lead to separation. I also understand that either the Red Cross or I can conclude, with or without cause and/or notice, my volunteer service at any time. If accepted, I will abide by the rules of the American Red Cross. I understand that completing the application process does not guarantee acceptance as a volunteer. Signature: Date: INFORMATION RELEASE I give the American Red Cross, its designees, agents and assigns, unlimited permission to use, publish and republish in any form or media, information about me and reproductions of my likeness (photographic or otherwise) and my voice, with or without identification of me by name. Signature: Date:

4 Optional Self Identification The American Red Cross Blood Services, Badger-Hawkeye Region, is an equal opportunity employer. In recognition of its responsibility to its paid and volunteer staff, and the community it serves, the Red Cross affirms its policy to assure fair and equal treatment in all its employment practices for all persons. We consider applicants for all positions without regard to race, color, religion, sex, age, national origin, disabled or veteran status, or other legally protected status. To help us track our organizational success, we ask your assistance in filling out this voluntary self identification form. In addition to our internal tracking, the Red Cross must meet government record-keeping and reporting requirements. Completion of this form is voluntary and will not affect your volunteer application. This information will be kept in confidence and not accompany your application to prospective supervisors. Gender:? Male? Female Date of Birth: / / Veteran:? Yes? No Do you have a disability? If yes, are you a disabled veteran?? Yes? No? Yes? No Ethnic Origin:? Native Hawaiian / Other Pacific? White / Caucasian? Asian? Hispanic / Latino? Black / African American? American Indian / Alaskan Native PLEASE RETURN YOUR COMPLETED APPLICATION TO: American Red Cross Blood Services Volunteer Office 4860 Sheboygan Avenue Madison WI Volunteer Services Supervisor Kathleen Van Den Wymelenberg vandenk@usa.redcross.org phone

5 Applicant s Disclosure & Consent Release Form for Information and Consumer Reports In connection with my application for volunteer employment (including contract for services), I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including but not limited to criminal records, driving record, education, prior employer verification, workers compensation claims, drug/alcohol tests, and others. These reports will include experience along with reasons for termination of past employment. Further, I understand that you may be requesting information from various Federal, State, local and other agencies which contain my past activities. All results will be kept confidential. The information obtained will not be provided to any parties other than to designated organizational personnel. I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information for employment purposes. I further authorize ongoing procurement of the above mentioned reports at any time during my employment (or contract). I do certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as a cause of possible dismissal. Print Name : First, Middle, Last Current Address: Former Address: Resided from to Former Address: Resided from to Telephone Number (including area code) Social Security Number - - Driver s License #: Issuing State: FOR IDENTIFICATION PURPOSES Other or former names Dates Used: to Other or former names Dates Used: to Date of Birth: / / Signature Date Last updated 7/03 My initials provided in the box and the date entered on the line above serve as my electronic signature that everything I have mentioned is true and correct to the best of my knowledge and belief.