VolunTEEN Summer Application Form 2014

Please return this registration form to Amber Moore at or 701 N. Raleigh Blvd, Raleigh NC 27610 by May 16th. VolunTEENs must attend the summer staff training, Saturday May 31st at the Raleigh Boys Club at 10 am until noon.

Date ______

Personal Information

Full Name ______Birth date______

Current Address ______

City______State ______Zip ______

Home Phone _(___)______Mobile Phone _(___)______

Email Address ______

Social Security ______(required for all background checks)

Have you previously been a member, volunteered, or employed at any Boys & Girls Clubs? Check one ____YES ___NO

If yes, when and where? ______

CurrentHigh School ______

Current Grade in School ______

Graduation or Anticipated Graduation Date ______

Club Information

At which Boys & Girls Club would you like to volunteer:

___Raleigh Girls Club

___Washington Elementary Boys

& Girls Club

___Raleigh Boys Club

___Brentwood Boys & Girls Club

___Zebulon Boys & Girls Club

___WakeForest Boys & Girls Club

___Boys & GirlsClubTeenCenter

Availability:

Please mark the session that you would like to volunteer:

_____ June 16 – June 27

_____ June 30 – July 11 (clubs closed 7/4)

_____July 14– July 25

_____ July 28 – August 8

_____ Other (______)

Will you seek academic credit for this experience? ____ Yes ____ No

If seeking academic credit, students are responsible for obtaining and meeting their specific program requirements. Boys & Girls Clubs will provide necessary documentation for credit upon request.

Availability

Please list days and times that you are available

Mon. / Tues. / Wed. / Thurs. / Fri.
Time
available

ADDITIONAL INFORMATION

Please circle the applicable response:

Do you currently use illegal drugs? Yes No

Have you ever been convicted of a criminal offense? Yes No

Have you ever been convicted of child abuse or neglect or

is there a pending criminal charge against you for child abuse

or neglect? Yes No

Has your driver’s license been suspended or revoked? Yes No

Are there any other facts or circumstances involving you or

your background that would call into questions your being

entrusted with the supervision, guidance and care of

young people? Yes No

Please use a separate sheet of paper to explain any “Yes” responses.

Attachments

Please submit the following materials as part of your application package

Personal Statement: Please write a short statement addressingyour post high school academic goals. Please keep the statements between one-half or one page.

UNDERSTANDING AND AUTHORIZATION

I certify that all the answers on the application and any attachments are true and complete to the best of my knowledge. I also certify that I have not withheld any pertinent information.

I agree that in the course of considering my application, you may inquire to verify information considering my background. I specifically authorize you to investigate all statements in the application. I authorize educational institutions, employers and references listed above to give you any and all information concerning my education, employment and fitness to work with children and young people. I further agree to release and hold harmless the Boys & Girls Clubs, institutions, references listed above and any law enforcement agencies from all liability and any damage that may result from furnishing this information to you.

Applicant’s Signature: ______

Parent’s Signature: ______

Date: ______

Emergency Information

Emergency Contact’s Name ______Relationship ______

Phone (___ ) ______Alternate Phone ( ___ ) ______

Hospital Insurance Information

Cardholder Name ______Cardholder ID ______

Please list any allergies, relevant medical history, medical conditions, or pertinent medications:

______

Food Restrictions: ______

Medical Release:

I accept responsibility in the unlikely event that an accident might take place. I hereby certify thatI carry Health and/or Accident Insurance for my child and that I am solely responsible for the costor health care for my child; even as a result of my child’s participation in Club programs oractivities. I further certify that my child is covered by medical insurance as listed on the aboveemergency information form. I understand that I am solely responsible to provide such coverage.I understand that I am solely responsible for any consequences of my failure to provide adequateinsurance coverage. I agree to abide by all rules of the Boys & Girls Clubs pertaining to healthand safety of the members and to inform the Club immediately of any change in my child’s health,health care insurance, or medical provider. I also give permission to Boys & Girls Clubs to seekimmediate necessary treatment for my child if necessary.

______

Guardians Signature

Campers’ Personal Property

Neither the Boys & Girls Clubs, Staff or Volunteers shall be responsiblefor the loss of, or damage to personal property of the participant. We urge participant to not bringradios, video games, or other expensive items to camp to prevent loss or theft. Boys & GirlsClubs, Staff, and Volunteers will not be responsible for lost or stolenitems.

Property Damage
I will be responsible for, and pay, for damage done by my child.

Voice and Likeness Release:

I understand that the VolunTEEN summer program is an outreach project created by Boys & Girls Clubs, By this release, I consent to theuse of _my child’s likeness and voice, including all photographs, video, internetuse, and sound recording for educational or promotional purposes by Boys & Girls Clubs, or anyone authorized by these organizations. I acknowledge that Boys& Girls Clubs are the sole owners of all rights to such materialon my child’s participation. I understand that I shall receive no compensation for my child’sappearance and participation in this project. If the participant is a minor child, I represent that I amthe parent/guardian and I hereby consent to the foregoing on his/her behalf.

______

Guardian’s Signature Date