Volunteer Application - Castle Home Care

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Volunteer Application

Last Name * First Name * MI Date of Birth *

Address * City * State * Zip *

Phone Number (ex. 555-555-5555) *

Alternate Phone Number

Social Security Number *

List 2 references names and phone number of whom we can contact:

Reference #1 Full Name

Reference #1 Phone Number

Reference #2 Full Name

Reference #2 Phone Number

Have you ever been convicted of a crime or pleaded “No contest” for any offense or violation other than minor traffic violations? No Yes *

If yes, describe:

Nature of the crime(s)

Date of conviction(s)

Country & State where issued

Do you have any pending criminal charges against you? Yes No *

If yes, describe:

Nature of the crime(s)

Date of conviction(s)

Country & State where issued

Photo release for an adult: (anyone who has reached the age of 18)

As a volunteer I Give Castle Home Care, Inc. permission to use my name and/or picture in their newsletters, brochures, website or posters in an effort to share with others the activities that I participate in at Castle Home Care, Inc. Do Not give Castle Home Care, Inc. permission to use my name and / or picture in their newsletters, brochures, website or posters. *

Please read the following before signing:

All information contained in this volunteer application is true and correct to the best of my knowledge and belief. I understand that I may be subject to the same pre-employment screening and background checks as paid employees performing similar duties. I understand that misrepresentations or omissions of any kind may result in the denial of a volunteer position or may be a cause of subsequent dismissal if I have already been accepted to volunteer for Castle Home Care, Inc.

I authorize Castle Home Care, Inc. to investigate all of my responses on this application and contact any or all of my references. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my volunteering.

I am volunteering solely for the personal purposes or benefit without promise or expectation of compensation, benefits or future employment from Castle Home Care, Inc.

Applicant's Signature * Date *