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Compeer Volunteer Application Form
Volunteer Application
* Required
Name*
:
Gender:
Date:
Address:
City:
State:
Zip Code:
Date of Birth:
Phone:
Best Time to Call:
Email*:
Race:
Religion:
Marital Status:
Single
Married
Significant Other/Partner
Widowed
Age & Gender of Children:
Emergency Contact:
Phone:
Relationship:
Do you have any medical or psychological problems that significantly affect your health?
Yes
No
Explain:
Tell us about:
How did you learn about Compeer Niagara?:
Why do you want to volunteer for Compeer Niagara?:
Would you prefer to be matched with:
An adult
A Child
Undecided
Preferred age range:
Why?:
Best Day for you to volunteer:
Mon-Fri
Sat/Sun
Best time for you to volunteer:
Morning
Afternoon
Evening
What hobbies, special interests, or skills do you have?
How do you spend your leisure time?
Do you have any club or organization affiliations?
Anything else you would like us to know?
Employment History and References
Please provide us with your employment/volunteer history including names of supervisors.
Supervisors may be contacted for a character reference. We also require two personal references who
can comment on your ability to serve as a volunteer. The reference cannot be a relative and must have known you for at least one year.
Employment/Volunteer History
Please list your employment/volunteer history beginning with your current employer. (If retired, please list last employer)
Employed/Volunteered (from/to):
Agency:
Supervisor:
Address:
Phone:
Employed/Volunteered (from/to):
Agency:
Supervisor:
Address:
Phone:
Personal References
Must not be a relative. Must have known you for at least one (1) year.
Name:
Phone:
Relationship:
Address:
City:
State:
Zip Code:
Name:
Phone:
Relationship:
Address:
City:
State:
Zip Code:
Additional Information
Because of the nature of the population we serve, it is essential that we screen all our volunteers carefully.
Your cooperation in completing this form is appreciated.
A "YES" TO ANY QUESTION DOES NOT NECESSARILY DISQUALIFY YOU FROM BECOMING A VOLUNTEER.
ALL INFORMATION WILL BE HELD IN CONFIDENCE.
Name:
Date of Birth:
Driver's License ID Number (This is the 9 digit number located above your photo):
Expiration date of your license:
Has your license ever been suspended?:
Yes
No
If yes, please explain:
Do you have use of a car?:
Yes
No
Do you have auto insurance?:
Yes
No
Agency Name:
Have you ever been convicted of a crime (except minor traffic violations)??:
Yes
No
Explain:
Are there any misdemeanor/felony
charges pending against you now?:
Yes
No
If yes, give date and nature of charge(s):
I UNDERSTAND that it is my responsibility to maintain liability coverage during the time when I will be transporting
Compeer Niagara participants. I understand that if at any point I do not have liability coverage, I will refrain from
transporting Compeer Niagara participants and will inform Compeer Niagara staff.
I UNDERSTAND that as a volunteer, I will support the person I am matched with to the best of my ability in
accordance with the policies of Compeer Niagara and the Mental Health Association in Niagara County Inc.
I WILL maintain complete confidentiality concerning all information on Compeer Niagara persons. I further
understand that submission of a completed application, along with an interview by Compeer Niagara staff
and the mandatory training does not obligate me to accept or Compeer Niagara to assign a volunteer match
or any other volunteer opportunity.
I CERTIFY that the above information is accurate and give the Mental Health Association in Niagara County, Inc.
and its Compeer Niagara programs my permission to verify this information with the appropriate agency.
Volunteer Signature:
Date:
36 Pine Street
Lockport, New York 14094
Phone: 716-433-3780
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