Volunteer

Name*

Any previous names*

Address*

Email Address*

Phone*

Date of Birth (required for background check)*

Area(s) of interest for volunteering:*

List any education, training, or experiences you have had which would help us in meeting the needs of our students:

References: List three persons who can comment on your character and abilities whom we may contact. Please provide name, address, and telephone number.*

Name	Address	Telephone number

If you have lived outside of the state of Virginia, please list states and dates:*

State	Date

Are you, or have you ever been, listed on a sex offender registry?*

Yes
No

Are you, or have you ever been, listed on a child or defendant adult abuse registry?*

Yes
No

Have you ever been found guilty, accepted a guilty or Alford Plea, or entered a plea of no-contest for any criminal charge?*

Yes
No

Have you ever received a deferred judgment, or in some other way had a guilty plea or conviction removed from your record?*

Yes
No

Have you ever been asked to resign from a position, or been given the choice of resigning or being terminated from your position?*

Yes
No

If you answered “yes” to any of the above questions, provide date, incident, specific charge, city/state in which occurred:*

Have you ever been the subject of an investigation or other formal/informal proceeding that resulted in the termination of your employment or resignation?*

Yes
No

Have you ever been the subject of an investigation into wrongdoing or other formal/informal proceeding, resulting in disciplinary or criminal action?*

Yes
No

If yes, briefly explain.*

Refusal to provide authorization for reference and/or criminal records checks and/or providing false or misleading information on this registration shall constitute sufficient reason to deny approval to serve as a volunteer or termination as a volunteer in the Shenandoah School of Hope, Inc. I understand that the Shenandoah School of Hope, Inc. performs reference and criminal records checks on all volunteers and I authorize persons and entities contacted by the Shenandoah School of Hope, Inc. in connection with this application to provide information about me. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Shenandoah School of Hope, Inc., its agents and officials or against any provider of such information. I further understand that if I am approved as a volunteer, that I will be required to sign a Volunteer Agreement and attend a Volunteer Orientation.

Full Name*

Signature*

Date*

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