Volunteer Form

Instructions for Completing the Background Check Authorization form, DSHS 09-653

1 Start 2 Page 2 3 Page 3 4 Complete

Contact Information

Name *

Street Address *

City, State, Zip Code *

Home Phone

Cell Phone

Email *

Availability

During which hours are you available for volunteer assignments? *

Certificates

Do you have any of the following (check all that apply, and list date obtained)

If other, please list:

Special Skills or Qualifications

Summarize specific skills and qualifications you have acquired from employment, volunteer work, or training/ed.

What inspires you to want to volunteer at Tierra Village?

Previous Volunteer Experience

Summarize your previous volunteer experience.

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I also understand that all Volunteers are required to complete a criminal history disclosure statement and background screening prior to appointment.

Type Your Full Name *

Date *

Month

Day

Year

Our Policy

Tierra Village is an equal opportunity employer. No employees and/or volunteer or applicant for employment shall be unlawfully denied an employment opportunity because of race, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, place of birth, age, veteran status, disability, pregnancy, genetic information, or other category protected by law. Tierra Village is committed to non-discrimination in its employment. Thank you for completing this application form and for your interest in volunteering with us.

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