Volunteer Application & Confidentiality Form

Personal Information

Full Name

Middle Initial

Preferred Name

Date of Birth

This address will receive a confirmation email

Phone

Address

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

Volunteer Area of Interest

Availability (Days & Times)

Skills, Strengths, and/or Spiritual Gifts

Community Service Volunteers Only

My Community Service is: School Related Court Appointed Other (Please explain below)

Reason you selected

Are you on probation or parole?

If you are on parole, what is your PO's name & phone number?

Church Information & Reference

Church Name

Church Phone

Pastor or Church Leader Name

Mission, Vision & Values

I have received and read a copy of Love INC's Mission, Vision, and Value's statement and I agree with it.

Yes

Electronic Signature (Type Full Name)

Criminal Background Check

Love INC does a criminal background check for every volunteer. The information needed for the background check is your name, date of birth, race and consent.

Date of Birth

Sex

Male Female

Race

American Indian or Alaskan Native Asian or Pacific Islander Black White Other/Unknown

I give permission for a background check.

Yes

Electronic Signature (Type Full Name)

Volunteer Confidentiality Agreement

I agree to protect the confidentiality of all individuals who have requested or have received assistance from Love In the Name of Christ of Muskegon County. I will not discuss or disclose information regarding any client to unauthorized persons outside of the Love INC sphere of service.

In addition, I will not discuss or disclose information regarding any volunteer or staff member to persons outside the Love INC sphere of service without written permission to do so.

Confidential information includes, but is not limited to:

- Names
- Birthdays
- Addresses
- Telephone Numbers
- Employment Information
- Social Security Information
- Legal Information
- Financial Information
- Medical Information

Electronic Signature (Type Full Name)

Volunteer Application & Confidentiality Form

Description

Please Fix the Following