Mars-Bros Mentoring Program

Today’s DateOakdale Neighbors

Volunteer Application

1260Kalamazoo SE, Grand Rapids, MI49507

Email: eb:

Phone: 616-248-2848

Fax: 616-452-1763

PERSONAL INFORMATION:

NameDate of Birth

Address

(street)(city)(state)(zip)

Home TelephoneOther TelephoneE-mail

Volunteer position or role interested in:

Please indicate your level of commitment:

2-4 hours annually

2-4 hours monthly

2-4 hours weekly

2-4 hours daily

EDUCATIONAL BACKGROUND:

High SchoolLocationDates Attended

Post-Secondary SchoolLocationDates AttendedDegree and Major Course of Study

WORK EXPERIENCE:List your current employment experience:

DatesPosition, Title, or Role

Employer’s NameEmployer’s Address

Supervisor’s NameSupervisor’s JobTitleSupervisor’s TelephoneSupervisor’s Email

May we contact your supervisor?

Yes

No

WORK EXPERIENCE: List your previous employment experience:

DatesPosition, Title, or Role

Employer’s NameEmployer’s Address

Supervisor’s NameSupervisor’s Job TitleSupervisor’s TelephoneSupervisor’s Email

May we contact your supervisor?

Yes

No

VOLUNTEER EXPERIENCE:List previous volunteer positions which you have held.

DatesPosition, Role, or TasksOrganization

Church attending:

Are you willing to drive your car during your volunteer service?

No

YesDriver’s License Number:

Pease list traffic violations received within the last three years:

PERSONAL PHILOSOPHY:

Why are you interested involunteering with Oakdale Neighbors? Include personal or spiritual goals or motivations.

What talents, skills, hobbies or interests can you contribute to the work of Oakdale Neighbors?

PERSONAL REFERENCES:

Give the names, addresses, and telephone numbers of TWO persons/friends who have known you for the past three years and can speak about your character. Give the name of ONE professional (supervisor, pastor, professor). Please do not name relatives.

1. NameRelationship to youEmail AddressTelephone No.

2. NameRelationship to youEmail AddressTelephone No.

3. NameRelationship to youEmail AddressTelephone No.

By signing below, I indicate that I have read this document carefully, that I understand and agree to its terms, that I recognize that it constitutes a waiver of legal rights, and that it is enforceable to the extent allowed by law:

I hereby declare the information provided is true, correct and complete to the best of my knowledge. I understand that any misstatement or omission of fact on this application will be considered cause for my dismissal.

As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by Oakdale Neighbors.

I understand that I or my child may be photographed, video/audio recorded, and/or interviewed for program promotion, recognizing that information may be used on the web, television, radio, or in print.

I am informed of the activities offered by Oakdale Neighbors, that I am aware of the potential dangers/risks of engaging in the observation, activities or instruction offered by Oakdale Neighbors, that I assume all risks associated with such dangers and risks, and am fully aware of and understand the terms and the legal consequences of the signing of this Release.

I intend by this agreement to exempt and relieve Oakdale Neighbors and its officers, agents, servants, volunteers, or employees from liability for personal injury, property damage or wrongful death of me or my child caused by any act of negligence of Oakdale Neighbors and its officers, agents, servants, volunteers, or employees. For and in consideration of my engaging in or permitting my child to engage in any activity or activity incidental thereto some of which may involve dangers and risk of bodily injury through Oakdale Neighbors, I hereby voluntarily and absolutely release, discharge, waive and relinquish any and all loss or damages or actions or causes of action for personal injury, property damage or wrongful death occurring to me or my child as a result of my or my child's engaging in any activities wherever or however the same may occur, and for whatever period said activities or instructions may continue.

I, my heirs, executors, administrators or assigns, agree that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Oakdale Neighbors or its officers, agents, servants, volunteers, or employees, I will indemnify and hold harmless Oakdale Neighbors and its officers, agents, servants, volunteers, or employees from any and all claims or causes of action by me or my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will I present any claim against Oakdale Neighbors and said persons for personal injuries, property damage, wrongful death or otherwise, caused by any act of negligence by Oakdale Neighbors and said persons.

If any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I hereby authorize Oakdale Neighbors to conduct a comprehensive review of my background causing a report to be generated. I understand that the scope of the report may include, but is not limited to the following areas: verification of social security number, current and previous residences, employment history, education background, character references, drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions, driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Oakdale Neighbors or its agents.

______

APPLICANT’S SIGNATUREDATE

If you are under age 18, a parent or guardian should complete this section:

______(I am the parent or legal guardian of ______)

PARENT PRINTED NAME"my child"

______

PARENT SIGNATUREDATE