Volunteer Application

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~Volunteer Application~

Please complete this application form if you are interested in becoming a Counting Strides, Inc. volunteer.
Please be sure to click the "Submit" button when you have completed this form.

All volunteers are required to:
- Submit a Volunteer Application
- Successfully complete a background check
- Interview with Director of Human Resources

* Indicates REQUIRED INFORMATION.

General Information
Please include at least one phone number where we can reach you during business hours and an email address that you check frequently. Your information is confidential.

First Name Middle Last Name

Title Nickname Email Address:

Address

City State Zip Code

Home Phone Cell Phone Work Phone

T-Shirt Size

Demographic Information

Date Of Birth SSN Gender

Emergency & Health Information
We will attempt to contact the following person in the event of a personal emergency

Medical Insurance Company Policy #

First Name Middle Last Name

Address

City State Zip Code

Home Phone Cell Phone Work Phone

Relationship To You Physician Name & Number

Do you have any life threatening allergies requiring Eppi Penn? If So, Please list

Please list any medications you are taking and why

Do you have any physical, emotional or other limitations that may limit your ability to volunteer in certain areas or for certain lengths of time? If So, please describe briefly.

Education Information
Please fill in based on your current level of education.

I Have Completed

Please List the Names & City, State of the High School, Trade School & or College You Have Attended

Employment Information

Company or Organization

Address

City State Zip Code

Phone Fax Website

Title Duties

Professional Skills and /or Special Abilities
Please indicate any of the following skills or abilities that you possess. (Professional experience is not required.) If you have other skills or abilities that might be valuable , please list them in the space provided.

Skills:

Accounting	Artistic Abilities	American Sign Language	Attorney
Chef / Catering	Child Care & Development	Clerical / Office	Cleaning/House Keeping
Computer	Construction	CPR & First Aid	Customer Service
Data Entry	Drafting/Design/ Blueprints	Editing / Proofreading	Education / Teaching
Electrician	Engineering	Equine Care/ Maintenance	Equine/Farm Management
Foreign Language	Fundraising	Graphic Designer	Grant Writing
Horticulture Landscaping	Law Enforcement	Maintenance / Repair	Mechanic
Non-Profits	Nurse/Paramedic/EMT	Painter	People Skills
Photography	Psychologist	Public Speaking	Real Estate
Riding Instructor	Sales	Special Events	Stable Hand
Therapeutic Riding	Therapist	Training	Vet Care - Tech
Victim of Abuse	With Abused Women	With Abused Children	With Teens

Other Skills or Additional Details of Indicated Skills

Past Volunteer Positions

Availability
Please indicate the days and time periods that you are available for volunteering

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
Morning:
Afternoon:
Evening:

My availability is From TO

Additional Information About My availability is

Testimonial

Please describe in detail your experiences and why you feel Counting Strides is the right place for you to volunteer your skills.

Personal References
List two non-family references who have known you for at least one year and provide at least one phone number for each reference.

First name:	*	First name:	*
Last name:	*	Last name:	*
Title:		Title:
City:	*	City:	*
State:	*	State:	*
Day phone:		Day phone:
Evening phone:		Evening phone:
Email address:		Email address:
Relationship:	*	Relationship:	*

Background Check Information

I understand, in consideration of my application, a background investigation will be conducted. I understand this investigation may include, but is not limited to, a criminal background check in the files of any Federal, state or local justice agency, driving history, performance of medical examinations, drug screening or reference verification. I authorize Counting Strides, Inc. and associated entities to conduct the background investigation and release Counting Strides, Inc. from responsibility for this investigation.

I understand the requested information is for the sole purpose of gathering accurate information for volunteer services at Counting Strides, Inc. I understand that for the protection of visitors, clients and students, volunteers and staff must voluntarily authorize a background check and I hereby authorize such background check by submitting this application.

Do you know of any reason (s) that you might not be able to obtain a clear background check? If yes, please explain briefly

Waiver and Release of Liability
In consideration of being allowed to volunteer my services at Counting Strides, Inc., I hereby acknowledge that there are certain risks of injury involved, and I knowingly and freely assume all such risks and assume full responsibility for my participation. To the extent allowed by law, I agree to indemnify and hold harmless Counting Strides, Inc., its officers, employees, agents, representatives and volunteers, of all liabilities and all loss or damage to person or property which may occur or be incident to my involvement or participation.

Volunteer Confidentiality Agreement
I recognize that as a volunteer of Counting Strides, Inc., I may have access to confidential information concerning Counting Strides, Inc., its guests, customers, agents, employees, volunteers or representatives. In consideration of any volunteer status with Counting Strides, Inc., I agree I will not at any time, during or after volunteering for Counting Strides, Inc., divulge or reveal to any person, firm, or corporation, any information (including, but not limited to, personal or financial information or customer lists), directly or indirectly, which might in any way be used to injure or interfere with the business or cause of Counting Strides, Inc., or to alienate guests, customers, agents, employees, volunteers or representatives from Counting Strides, Inc. or to cause discontent or dissatisfaction among any such persons.

I agree that should I have any questions as to the propriety of release of any information, I will request clearance from Counting Strides, Inc. prior to releasing such information.

BY CHECKING THE FOLLOWING "I AGREE" BOX, I UNDERSTAND THAT I AM INDICATING MY AGREEMENT WITH THE TERMS OF ALL THREE PRECEDING SECTIONS.

I Agree