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Domestic Violence Awareness
Home
Agency Overview
Resources
Services
FAQs
Outreach
Volunteer Information
Online Chat
Client feedback
Contact
Donate/Fundraising Campaigns
Domestic Violence Awareness
Catherine Cobb Safe House Volunteer Application
Section 1: Volunteer Application
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Indicates required field
Name
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First
Last
Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Email
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Summer Address (College Students)
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How did you hear about volunteering?
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Are you willing to participate in on-going Volunteer development?
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Yes
No
Please list previous experience as a volunteer or employee in the Human Services area:
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Please list previous experience as a helping person:
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Please list your strengths and weaknesses in assisting a person in need:
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Have you ever had any experience assisting a person in crisis, or in an abusive situation?
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Yes
No
If Yes, what was your role?
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Is there anything else you would like to tell us about yourself?
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Section 2: Interests and Availability
Main Areas of Interest
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Shelter Support (General Duties)
Helping with physical maintenance
Interacting with clients (women)
Interacting with clients (children)
First Response Team
One-on-one parent mentoring
Teaching skills (computers, cooking, resume writng, etc.
Please specify skills:
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Number of hours available per month:
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Days Available
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time of Day
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Morning
Afternoon
Evening
Additional comments on interests or availability:
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Section 3: Confidentiality
Summary of Confidentiality Policy for Volunteers and Visitors
It is the policy of the Catherine Cobb Domestic Violence and Sexual Assault Program (CCDVSAP) to hold confidential all communications, and information made by, between, or about a client.
Records and information covered by the volunteer and visitor confidentiality regulations include:
1. Client Identity 4. Treatment
2. Prognostic 5. Client Status Information
3. Diagnostic 6. Physical Whereabouts
I understand by signing this form that I agree to keep all information about clients, volunteers and staff, including names and shelter location,
strictly
confidential while performing any tasks here at the shelter location. Violation of this policy will be considered grounds for terminating services and relationship with CCDVSAP and may have legal penalties.
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I have read the above confidentiality policy.
Typing your full name contitutes signing and agreeing to the above confidentiality policy.
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Section 4: Criminal History Information
Have you ever been convicted of any criminal offense, other than minor traffic violations?
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Yes
No
If Yes, please explain:
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As an employee/volunteer of Family Counseling & Children's Services of Lenawee County, I understand that it is the agency's policy to secure conviction criminal history information as part of their employment screening process using the information provided below.
Last Name
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First Name
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Middle Name
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Maiden Name/Names Previously Used
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Birthdate
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Race
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Gender
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Male
Female
Driver's License Number
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I understand that the above information is required by the Central Records Division of the Michigan State Police, Lansing, Michigan. By typing my name below I authorize Family Counseling & Children's Services of Lenawee County to utilize the above information for the sole purpose of obtaining a conviction criminal history file search. Please type your full name below to agree to a criminal background check.
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