VOLUNTEER POSITION *

    DATE *

    FIRST NAME*

    LAST NAME*

    STREET NAME*

    CITY*

    STATE*

    ZIP CODE*

    PHONE NUMBER*

    VOLUNTEER EMAIL*

    LANGUAGES KNOWN

    LIST ANY TRAINING/CERTS YOU HAVE RECEIVED FROM VOLUNTEERING

    HOBBIES/SPORTS*

    WHAT CAREER ARE YOU INTERESTED IN?*

    PERSONAL TALENTS/SKILLS*

    WHEN YOU THINK OF VOLUNTEERING, WHAT THINGS INTEREST YOU?*

    SCHOOL ACTIVITIES INVOLVED IN

    WHY DO YOU WANT TO VOLUNTEER?

    Emergency Information

    EMERGENCY CONTACT NAME*

    RELATIONSHIP

    DAY PHONE*

    ADDRESS*

    EVENING PHONE*

    Volunteer Availability

    WHAT DAYS ARE YOU AVAILABLE?*

    AT WHAT TIME OF THE DAY ARE YOU AVAILABLE?*

    TELL US HOW YOU FOUND OUT ABOUT BECOMING A HEARTBEAT OF CHAMPION VOLUNTEER*

    Additional Application Requirements: All volunteers must sign a Volunteer Service Agreement and Release.
    Consent Statement: I hereby certify that all the statements made in connection with this application for a volunteer assignment are true, accurate, and complete. Background criminal screens for volunteers in certain assignments may be required. I hereby authorize Heartbeat of Champions (HOC) to obtain a record of my criminal convictions from the California Department of Justice or any other agency that collects records of criminal conviction. I hereby authorize a designee of HOC to verify any written representations made by me, concerning or included in the application to be a volunteer with HOC. I understand that any and all information obtained related to a screening event is confidential and must be maintained in the strictest confidence and treated with care. I understand that HOC is not responsible for any liability arising out of my participation in screening event. I hereby agree to abide by all confidentiality regulations and volunteer guidelines outlined by HOC. I further agree to indemnify and hold harmless HOC, and any individual, firm or officer affiliated with HOC, against any claim, dispute, or other cause of action arising from my participation in the screening event.

    FULL NAME *

    VOLUNTEER PERSONAL RECORD
    (download and bring to interview)
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