Signing this Application constitutes written authorization for our agency to complete a security background check and motor vehicle abstract report if the volunteer position requires driving on vrc business



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VRC Volunteer Opportunities & Application
Volunteer Opportunities: shelter volunteer, sexual assault volunteer, Foster Pet Care, secretarial volunteer, Special Events Volunteer, Board of Director’s, Community Volunteer. For more information call (315) 331-1171 ext. 306.
Signing this Application constitutes written authorization for our agency to complete a security background check and motor vehicle abstract report if the volunteer position requires driving on VRC business.
Name: ___________________________________________________ (Maiden/birth name): ________________________

Address: ____________________________________________________________________________________________

City: ______________________________________________________ State: _______________ Zip Code: ___________

Phone numbers: home: ________________________ cell: _________________________ work: ____________________

Email Address: ______________________________________________________________________________________

Social Security #: _______________________________________ Birth Date: ___________________________________

Days and times available: ______________________________________________________________________________

Work Experience: ____________________________________________________________________________________

References: List three names of persons not related to you who can provide information on your abilities relevant to this position. Please list their name, phone number, and years known.


  1. _________________________________________________________________________________________

  2. _________________________________________________________________________________________

  3. _________________________________________________________________________________________

List any strengths, skills, hobbies or interests that you feel are relevant or beneficial to volunteering with the VRC?

________________________________________________________________________________________________________________________________________________________________________________________________________

What do you know about the crimes of domestic, sexual, stalking, family violence, and/or child abuse?

________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have a valid driver’s license and reliable transportation? ( ) Yes ( ) No

What types of volunteer service are you interested in doing at the VRC? __________________________________________

____________________________________________________________________________________________________

Arrest History/Criminal Background: Please list every state in which you have lived. List any arrests, or detainments by any law enforcement agency, and/or any indication by Child Protective Services. List the state, date, reason and outcome.

Have you ever been convicted of any crime other than a felony? ( ) Yes ( ) No



Are you a registered sex offender? (This must be disclosed by law) ( ) Yes ( ) No
“I understand my answers are given voluntarily and if I so desire I may consult an attorney before I sign this form. By my signature below, I fully understand that I have waived my right to consult an attorney. Under penalty of perjury I declare the aforementioned answers true to the best of my knowledge. By my signature below, I authorize the VRC to investigate via local and state police departments my background, criminal history, offender status (if any) and any other fact of my character. I forever hold the VRC, its employees, heirs, family, vendors and anyone else not stated herein and now, harmless for any and all information gathered and reported to the VRC. I understand that a false statement made herein is immediate grounds for termination without notice or cause.”

I, the undersigned, have read, understand and agree to all the terms of this release.
______________________________________________________________ Date ___________________________

Applicant Signature

______________________________________________________________

Print applicant name clearly
Mail to: Volunteer Coordinator, VRC, 132 Harrison Street, Newark, NY 14513-1234


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