Survey - Volunteer Form

Volunteer Form

Please fill out the following information:

Name:

First Required	Last Required

Email: Required

Street Address: Required

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

Employer: Required

Occupation: Required

Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from YWCA York.

*2.

Question - Required - Emergency Contact (please include name and phone number):

*3.

Question - Required - Do you have access to transportation?

*4.

Question - Required - Are you able to perform duties with/without accompaniment? If so, please explain.

*5.

Question - Required - Do you have any experience or training in the sexual assault/domestic violence or victimization fields? If yes, where?

*6.

Question - Required - How did you learn about the Victim Assistance Center and/or ACCESS-York?

*7.

Question - Required - Please list your volunteer background starting with your most recent experience. Please include the organization, position, duties, and date of volunteer work.

*8.

Question - Required - Why do you want to volunteer at Victim Assistance Center or ACCESS-York?

*9.

Question - Required - Please list at least two references and include the following information: name, address, phone number, email, how long you have known this person, and how do you know this person.

*10.

Question - Required - Please check the volunteer opportunities that interest you. Selection of a specific opportunity does not guarantee that you will be used in that capacity. This section simply helps us to determine which opportunities interest you. You will be provided with additional information about the opportunities that you select. All opportunities below pertain to both Victim Assistance Center and ACCESS-York programs unless otherwise specified.
Please make between 1 and 2 selections from the choices below.

	Indirect Service (requires some on-the-job training)
	Direct Service (requires 70 + hours of training)

*11.

Question - Required - VOLUNTEER AGREEMENT: I hereby acknowledge that I have been given and understand information about volunteer responsibilities, volunteer guidelines, and the confidentiality contracts of Victim Assistance Center and/or ACCESS-York, programs of the YWCA York. I agree that I shall be responsible for maintaining the confidentiality of Victim Assistance Center and/or ACCESS-York therein.

*12.

Question - Required - I understand that completing the volunteer training does not guarantee that I will be considered for direct service.

*13.

Question - Required - I fully understand that failure to adhere to this agreement could result in termination of my volunteer services to VAC and/or ACCESS-York.

*14.

Question - Required - Further, I hereby grant full permission to the aforementioned persons and organizations to use my name and/or picture in any newspaper, photograph, videotape, motion picture, recording, or any other account of this event for any purpose whatsoever.