UpperValleyHaven

Name (required)

Date of Birth (required)

Phone Number

Home Address

City, State, Zip

Email Address

What is your preferred method of communication? ---EmailTelephonePostal Mail

Are you able to communicate in a language other than English?  Yes No

If yes, which language?

Do you have a valid drivers license?  Yes No

Do you have regular access to a vehicle?  Yes No

Are you currently employed?  Yes No

If yes, please give your place of employment and position:

Current community activities:

List current and previous volunteer work (list all previous volunteer work including brief description of duties and activities, dates of service.):

What drew you to the Haven as a place to volunteer your time?

Have you ever been convicted of a crime other than a traffic violation?  Yes No

If yes, what charge?

Date convicted:

Where?

Level of Education ---High School: 9High School: 10High School: 11High School: 12College: 1College: 2College: 3College: 4Graduate: 1Graduate: 2Graduate: 3Graduate: 4

Major:

Degree:

Name of School:

Volunteer Availability (check all that apply)

Number of days per week  1 2 3 4 5

Days of the week  Mon Tues Wed Thurs Fri

Please list two references of people who know you well, preferably for whom you have worked in either a paid or volunteer capacity. If you are currently working, either paid or as a volunteer, please include the name of your supervisor.

Name

Phone

Relationship

Name

Phone

Relationship

The Upper Valley Haven Volunteer Confidentiality Agreement

All volunteers are responsible for maintaining and protecting the confidentiality of information as it relates to guests and clients of The Upper Valley Haven. Maintaining confidentiality will enhance trust between the guests and clients of The Upper Valley Haven and respect the guests and clients rights to privacy.

I, , as a volunteer of The Upper Valley Haven, do hereby affirm that I will treat all Upper Valley Haven guests, clients, and organizational information as confidential. I will not divulge any information regarding guests either directly or indirectly. I further understand that I convey information concerning guests and clients to my direct supervisor as necessary for the proper provision of service to the guests and clients. All requests for information by professional agencies or to the individuals will be referred to my direct supervisor.

In signing this statement, I fully realize the importance of maintaining confidentiality and that a violation of confidentiality could result in immediate termination as a volunteer. Should such a termination occur, I understand that my obligation to protect the confidentiality of both the guests and organizational information will continue after termination of my relationship with The Upper Valley Haven.

Signed By (required)

Date (required)

Please type the characters you see into the box on the right