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Student Volunteer Application

Date of Application: ______

First Name:
/
MI:
/
Last Name:
Address/City/Zip Code:
Phone Number(s): (Primary) (Secondary)
Email Address: / Date of Birth:

If this is for an Internship, Practicum, Field Experience, or any class requirement, complete this section:

Class Title______Major______

Hours Needed ______Which Semester? ______

Beginning Date ______Completion Date ______

Instructor Name______Phone #______Email______

What do you expect to gain from this experience? ______

______

______

Availability:

Morning

/ __Monday / __Tuesday / __Wednesday / __Thursday / __Friday / __Saturday / __Sunday
Afternoon / __Monday / __Tuesday / __Wednesday / __Thursday / __Friday / __Saturday / __Sunday

Office Use Only

Date Received: _____ Scheduled Orientation _____ Volunteer Database

_____ Background Check _____ Orientation Date _____ Car Insurance

Recent Employment History

/ Dates / Description of Work

Volunteer History

/ Dates / Description of Work

What are your gifts, talents, and interests?

Please list any physical limitations you may have:

Do you have a valid driver’s license? Yes / No Do you have liability insurance? Yes / No

EMERGENCY INFORMATION In case of an emergency, please notify:

Name: ______Relationship: ______

Contact Numbers: (H) ______(W) ______Cell: ______

I certify that the answers given on this application are true and complete to the best of my knowledge.

I authorize Stepping Stones of Dunn County to conduct a criminal record check.

Signature: ______Date: ______

Please read and then initial the following statements in the spaces provided.

Policies

I have read the work policies for students (separate handout) and agree to abide by them. ______

Confidentiality Statement

I understand that during my time as a worker with Stepping Stones I may have access to confidential information regarding clients served and other sensitive situations associated with the work of Stepping Stones. I understand that I must maintain the confidentiality of all observed, verbal, written, or electronic information. This includes not discussing with anyone other than Stepping Stones’ staff or volunteers (only as needed) the names of people who seek and/or receive services at Stepping Stones or their circumstances.

I agree to discuss confidential information only with others associated with Stepping Stones and only as it pertains to the clients’ well-being or my personal well-being in relation to the client. And I will not discuss these matters where they may be overheard.

I understand that violation of this confidentiality statement will be grounds for immediate dismissal. ______

Release of Liability Waiver

I agree to indemnify and hold harmless Stepping Stones of Dunn County, its officers, employees, volunteers or agents from any and all liability from damages, loss or injuries, either to person or property, which may be sustained while engaged in volunteer activity with Stepping Stones.

I fully understand the foregoing statement and sign the Liability Waiver knowingly, freely, and willingly.

______

Signature Date

Please either e-mail your completed application as an attachment to , dropt it off, or print and mail it to:

Volunteer Coordinator

Stepping Stones

1602 Stout Road

Menomonie, WI 54751

Thank you!