The Center Serving Persons With Mental Retardation

VOLUNTEER APPLICATION

* Fields marked by and asterisk (*) are mandatory fields and must be completed to process this application.
*Name *Date
*Address
*City, State, Zip +4
*Phone Home Work Cell/Pager Fax

*Birthday Social Security #: *E-mail:

Spouse’s Name Spouse’s Occupation: Spouse’s Employer

Answers to the following will assist the Community Relations Department in arranging appropriate placement in a volunteer
program.
What prompted your interest in The Center? ________________________________________________________________

*In what area are you interested in volunteering (Please choose from the volunteer opportunities listed in the packet you
received with this application)? __________________________________________________________________________

*When are you available to volunteer? Start Date: _________ Days Available: _________ Hours Available: ________

Are you employed? (Check one) Yes No If so, by whom? _______________________________________________

Does your employer sponsor either of the following? (Check one) Time-off Program Donation Matching Program

Highest level of education completed? (Circle One) Elementary 5 6 7 8 High School 9 10 11 12 13

College 1 2 3 4 5 Degree earned _______________________________________________________________________

Are you willing to accompany people to religious services? (Check one) Yes No
If so, please specify preferences, if any ____________________________________________________________________

*Are you certified in? (Check one) CPR First Aid

*Personal Reference *Person to contact in case of emergency
Name Name

Address _________________________________________ Address

____________________________________________
Relationship

Phone Phone

*Personal Reference *Business or Personal Reference

Name Name

Address _________________________________________ Address _____________________________________________

Phone Phone

The following is to be completed by every volunteer who will drive a CRI van or their personal car as a direct part of their volunteer duties.

Name as listed on Driver's License __________________________________________

Driver's License Number _________________________ Auto Insurance Carrier ____________________________________

If a volunteer uses a personal vehicle while engaged in volunteer services, bodily injury, property damage, and liability insurance must be
maintained with an insurance carrier admitted to do business in the state of Texas with limits meeting the standards of the financial
responsibility act of Texas. This means simply that a volunteer must carry the insurance that is already required by state law. All van drivers
must complete a short van certification procedure.

(Over Please)
*Have you ever been convicted of any misdemeanor or felony other than minor traffic violations?
(Check one) Yes No If "Yes" is checked, then the nature, time place and disposition of the case will be discussed in a
private interview with the Community Relations Director before placement is completed.

As a matter of policy and for the protection of the people we serve, The Center routinely conducts background checks. The
references you provide will be contacted by the Community Relations Department and this information, as well as that of the
background check, will be kept strictly confidential.

If you have not lived in Harris County for the past seven years, please list all previous addresses for that time period:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________

My signature gives permission for these background checks to be made and for my references to be checked. I will receive
the basic orientation, read the materials presented at that time, and I agree to follow the The Center policies and procedures
which pertain to volunteers. It is the policy of The Center Volunteer Auxiliary to consider all applications without regard to
race, color, creed, sexual orientation, national origin, sex, age, disability, or disabled veteran status.

As a volunteer you are a member of the Volunteer Auxiliary. The Auxiliary provides opportunities throughout the year for
volunteers to learn more about The Center, about mental retardation, and to meet other volunteers. I agree to attend the basic
volunteer orientation. If I choose a program whose activities involve driving The Center’s vans, my past driving record
will be checked and I agree to attend one of the regularly scheduled van orientations.

____________________________________________________________________________________________________
Optional:
These fields are not mandatory for this application to be processed. All information provided in this application is
confidential and information provided in this section is used for departmental statistical tracking purposes only.

Ethnicity: (Circle One) Caucasian American Indian Black Asian/Pacific Islander Hispanic Other

Religious Affiliation: _________________________

Gender: (Check one) Male Female

How did you hear about The Center: (Check one)

Internet Friend Current Volunteer Employee Volunteer Fair Other

*Signed: _____________________________________ *Date: __________________

(FOR OFFICE USE ONLY)

During orientation, among others, the following topics were covered:

1. Rights
2. Confidentiality
3. Basic Information for Field Trip Drivers (If applicable)
4. Epilepsy procedures

Orientation/Handbook(date)________ Bckgd Chk(date)________ Ref Chk(date)________ RO________ Comp(date)________

NT(date)________ Programs(date)________