INDIANA COUNTY YMCA VOLUNTEER APPLICATION

INDIANA COUNTY YMCA VOLUNTEER APPLICATION
Thank you for considering the YMCA as a place to donate your time and talents. Volunteers are vital to the YMCA.
Without them, we wouldn’t be able to meet the needs of the kids, families, and adults who live in Indiana County.
At the YMCA, we know that your time and talent are precious, and we want every minute you spend with us to be
worthwhile. That’s why we’re asking you to take a few minutes to fill out this application. It will help us begin to make
the right match between your skills and interests and the opportunities available.
You will find questions on this form about your background, former residences, places of employment, and so on. We
hope you’ll understand that, unfortunately, there are a few people who apply for volunteer jobs at the YMCA for the
wrong reasons. The YMCA, however, makes an active effort to prevent abuse. So even though we may know you well,
we reserve the right to conduct background and reference checks on all volunteers. It’s just one of the many ways we
help protect children and other vulnerable people served by the YMCA.
Thank you for your cooperation in this effort and your interest in the YMCA. If you have any questions about this or
any part of our application process, please contact
Shawn Sebring
Senior Program Director
724-4639622
[email protected]
Steven Frye
Director of Youth and Teen Programming
724-463-3377
[email protected]
Thank you for wanting to benefit the YMCA and our community.
Sincerely,
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
Today’s Date (Month/Day/Year): _______________________________________
Name________________________________________________________________________________________________________________________________________________
(Last)
(First)
(Middle)
Address ____________________________________________________________________________________________________________________________________________
City___________________________________________________________ State___________________ Zip___________________
Email: _______________________________________________________ Phone: Day _______________________________ Evening ______________________________
How long have you been at this address? ___________________
If you are a college student, what is your major(s)? _________________________________________________________
Social Security Number ___________-__________-______________
Are you 18 years of age or over?
well.)
No (If no, please have your parent or guardian sign the application as
Emergency Contact
Name ________________________________________________________________________________________________________________________________________________
Address _____________________________________________________________________________________________________________________________________________
City________________________________________________________________________________________ State _____________________ Zip __________________
Phone: Day ___________________________________________________________ Evening __________________________________________________________
Interests
How did you learn about volunteer opportunities at the YMCA? ______________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Why would you like to volunteer? ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Which departmental volunteer opportunities interest you?
____ Youth Sports/Programs
____ Adult Sports/Programs
____ Senior Citizen Programs
____ Teen Programs
____ Aquatics
____ Special Events
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
____ Other
724-463-YMCA
If you checked other, please explain. ________________________________________________________________________________________________________
Would you like to talk to someone further about what kinds of volunteer opportunities might match your skills,
talents, and interests?___________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Are there any particular skills, talents, or interests you’d like to share?
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________ _____
What other organizations have you volunteered for, if any?
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Are you a member of the YMCA? If so, which? (Membership is not required to volunteer.)
________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ ___________________________
Schedule of Availability
Please provide a weekly schedule of times that you are available. Please use the additional time slot spaces provided
if you are available for different time periods during a specific day:
Monday
Tuesday
Wednesday
Thursday
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
Friday
icymca.org
Saturday
Sunday
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Residences
Please list your former addresses (excluding your current address) starting with the most recent for the past 5 years
(attach additional paper if needed):
1. ____________________________________________________________________________________________________________________________________________________
Street address
______________________________________________________
______________
_______________________
City
State
Zip
From when to when? (Include month and year) ___________________________________________________________________________________________
2. ____________________________________________________________________________________________________________________________________________________
Street address
______________________________________________________
______________
_______________________
City
State
Zip
From when to when? (Include month and year) ___________________________________________________________________________________________
3. ____________________________________________________________________________________________________________________________________________________
Street address
______________________________________________________
______________
_______________________
City
State
Zip
From when to when? (Include month and year) ___________________________________________________________________________________________
(List any other places of residence on the back of this application or use additional paper)
Employment History
Please list your last three employers, starting with the most recent:
1. ____________________________________________________________________________________________________________________________________________________
Name of organization
Employed from when to when? (Include month and year)______________________________________________________________________________
Address ___________________________________________________________________________________________________ Telephone ___________________________
State job title and describe your work: ______________________________________________________________________________________________________
Name and title of immediate supervisor: ____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________________________________________________________
Name of organization
Employed from when to when? (Include month and year)______________________________________________________________________________
Address ___________________________________________________________________________________________________ Telephone ___________________________
State job title and describe your work: ______________________________________________________________________________________________________
Name and title of immediate supervisor: ____________________________________________________________________________________________________
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
3. ____________________________________________________________________________________________________________________________________________________
Name of organization
Employed from when to when? (Include month and year)______________________________________________________________________________
Address ___________________________________________________________________________________________________ Telephone ___________________________
State job title and describe your work ______________________________________________________________________________________________________
Name and title of immediate supervisor: ____________________________________________________________________________________________________
Military History
Date of entry: __________________________________ Date of discharge: ______________________________
Branch of service: _____________________________ Type of discharge: ___________________________________ Final rank: _______________________
Did you attend service school or receive special training?
If so, provide the school: _______________________________________________________________________________________________________________________
Training:_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ ___________________________
Education
(Note: Formal education is not required to be a volunteer. We welcome experience of all kinds!)
Level
Name and
Course of
Start and end
Did you
Degree or diploma
location
study
dates
graduate?
High School
Trade or Business
College
Other
Other skills (caring for children, languages, etc.)
________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________ _________________
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
Background
Please list here any other names you may have used in the past: _____________________________________________________________________
__________________________________________________________________________________________________________________________________________ ______________
Driver’s license number _________________________________________________ Driver’s license classification _________________________________
Have you ever been convicted of a criminal offense? ____Yes
____No
If so, what was it and when did it take place? ____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________ ______________
________________________________________________________________________________________________________________________________________________________
References
Please list three people besides relatives and employers whom you have known for at least two years, and who know
you well enough to provide us with a reference.
1. Name _____________________________________________________________ Relationship to you __________________________________________________
Address __________________________________________________________________________________________________________________________________________
Telephone _______________________________________________ How long have you known them? ____________________________________________
2. Name _____________________________________________________________
Relationship to you __________________________________________________
Address __________________________________________________________________________________________________________________________________________
Telephone _______________________________________________ How long have you known them? ____________________________________________
3. Name _____________________________________________________________ Relationship to you __________________________________________________
Address __________________________________________________________________________________________________________________________________________
Telephone _______________________________________________ How long have you known them? ____________________________________________
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA
YMCA of INDIANA COUNTY VOLUNTEER WAIVER AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING.
THIS IS A RELEASE OF LIABILITY AND THE WAIVER OF CERTAIN LEGAL RIGHTS.
THE UNDERSIGNED PERSON (the "Volunteer") hereby acknowledges an intent to volunteer for the YMCA
of Indiana County. The Volunteer freely and unconditionally waives and releases the YMCA and any and all of
its employees, representatives and agents and their successors and assigns (the “YMCA of Indiana County”)
from all liability to the Volunteer, his personal representatives, assigned heirs and next of kin for any and all loss
or damage and any resulting claims of demands due to injury to the person or property or death of the
Volunteer, including those caused by the alleged negligence of the YMCA. The Volunteer further agrees to
defend, indemnify and hold the YMCA harmless from and against any and all liabilities, demands, claims,
damages, suits, judgments and decrees, and court awards including costs, expenses and attorneys’ fees, on
account of injuries to or death of any person or persons or damage to any property arising out of or related to
the Volunteer’s intentional or negligent acts, errors or omissions for the duration of the Volunteer’s
participation.
The Volunteer understands that he / she is not an employee of the YMCA and agrees that he / she will not
receive any compensation or benefit nor be eligible for any coverage under the Pennsylvania Workers
Compensation Laws.
I HAVE CAREFULLY READ THE FOREGOING WAIVER, UNDERSTAND ITS CONTENTS, AND AM AWARE
THAT I AM RELEASING CERTAIN LEGAL RIGHTS. I ACKNOWLEDGE THAT I AM SOLELY RESPONSIBLE
FOR ANY INJURIES INCURRED WHILE VOLUNTEERING WITH THE YMCA.
Printed name of Volunteer
Signature of Volunteer
Date
If Volunteer is under 18 both Parents/Guardians must sign:
Printed name of Parent/Guardian
Signature of Parent/Guardian
Date
Printed name of Parent/Guardian
Signature of Parent/Guardian
Date
Emergency Contact:
Name
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
Telephone
icymca.org
724-463-YMCA
Volunteer Code of Ethics and Policies
1. Smoking or use of tobacco products in the YMCA programs or on YMCA property is
prohibited.
2. Using, possessing, or being under the influence of alcohol or illegal drugs WILL NOT BE
TOLERATED!
3. Any form of abuse of children WILL NOT BE TOLERATED including:
 Physical Abuse – strike, spank, shake, or slap
 Verbal Abuse- humiliate, degrade, or threaten
 Sexual Abuse – including inappropriate touching and exposure
 Mental Abuse (Self Esteem)- comparison, or criticism
4. Volunteers must treat everyone of all races, religions, and cultures with respect and
consideration.
5. Volunteers must use positive techniques of guidance, including positive reinforcement and
encouragement rather than competition, comparison, or criticism.
6. Volunteers shall abstain from humiliating or frightening discipline techniques.
7. Volunteers shall not use profanity in the presence of children or parents
8. Volunteers shall refrain from intimate displays of affection toward others in the presence
of children, parents, and staff.
9. Monetary and expensive gifts to volunteers are prohibited.
10. Volunteers must be free of physical and psychological conditions that might adversely
affect others.
11. Volunteers will do everything in their power to avoid being put in a situation where they
are alone with a (YMCA) child other than their own.
12. Volunteers will portray a positive role model for youth by maintaining an attitude of
respect, loyalty, patience, integrity, courtesy, tact and maturity.
I understand that allegations or suspicions of child abuse are taken seriously by the YMCA and
will be reported to the Indiana County Children’s Services for investigations and will pursue the
prosecution of child abusers to the full extent under the laws of this State.
I have read and understand the above Volunteer Code of Ethics and Policies:
Your signature: ___________________________________________________________________________________________ Date: _____________________________
Parent or Guardian’s Printed Name __________________________________________________________________________________________________________
Parent or Guardian’s Signature (If under 18): ________________________________________________________ Date: _____________________________
YMCA of Indiana County, 60 N. Ben Franklin Rd., Indiana PA 15701
icymca.org
724-463-YMCA