CWS Lancaster: Volunteer Application

General Information

First Name

Last Name

Email

Phone

Birthdate

Example: 01/01/1950

Home Address

Street

City

State

Zip Code

Occupations, Skills and Hobbies

Occupation

Company/Employer

Do you have any skills or hobbies that you can share with CWS and our clients?

YesNo

Please describe.

Do you speak any languages other than English?

YesNo

Please list them and describe your level of proficiency.

Volunteer Experience

Have you previously volunteered with CWS?

YesNo

How did you learn about our volunteer opportunities?

What motivated you to volunteer with CWS? Are you volunteering to fulfill a class requirement or community service?

Describe any experience you have working in a cross-cultural environment with language learners?

Availability and Schedule

Average number of hours per week you would like to volunteer

Please enter a number only, i.e. 3

First Date Available

Example: 01/01/1950

Your general schedule of availability

Example: Mondays, 3-4 p.m. Wednesdays, 9-11 a.m.

Would you be able to commit to an initial volunteer period of at least 3-6 months?

YesNo

Transportation and Accommodations

Do you have your own transportation and auto insurance?

YesNo

Do you have any physical conditions that may impact your activities?

YesNo

Please describe.

Connections

Are you part of a Welcome Team or group of volunteers?

YesNo

What is the name of the supporting organization or faith group?

List any other professional, civic or other organizations you belong to that you consider relevant to volunteering with CWS.

Emergency Contact

First Name

Last Name

Relationship to you

Phone

Background Screening and Consent

Volunteers are a vital part of achieving our goal of maintaining Lancaster as a welcoming community for refugees. We are thrilled to partner with you in this process!

Please understand that CWS Lancaster takes the safety of our clients very seriously. You will be provided with more information on additional clearances and materials required to volunteer with CWS Lancaster, including materials required for compliance with the PA Child Protective Services Act. You will receive a follow-up email with instructions after completing this form. CWS covers the cost of all volunteer background checks and offers an optional donation opportunity for those interested in contributing.

Please select the appropriate statement below:

I have been a resident of the Commonwealth of Pennsylvania during the entirety of the previous ten-year period from the date of this document.I have NOT been a resident of the Commonwealth of Pennsylvania during the entirety of the previous ten-year period from the date of this document, and I will obtain a FBI finger-printed criminal background clearance.

I have NEVER been convicted of any of the following types of offenses, including the attempt, solicitation or conspiracy to commit any of the following offenses:

a. Criminal homicide

b. Aggravated assault

c. Stalking

d. Kidnapping

e. Unlawful Restraint

f. Rape

g. Statutory sexual assault

h. Sexual assault

i. Involuntary deviate sexual intercourse

j. Aggravated indecent assault

k. Indecent assault

l. Indecent exposure

m. Incest

n. Concealing the death of a child

o. Endangering the welfare of a child

p. Dealing in infant children

q. Prostitution and related offenses

r. Crimes related to obscene and other sexual materials and performances

s. Corruption of minors

t. Sexual abuse of children

I confirm that the statement above is true.

Please confirm where applicable for the following statements:

I have NEVER been named as the perpetrator of a founded report of child abuse.Within the 5 year period immediately preceding the date of this document, I have not been convicted of a felony offense under The Controlled Substance, Drug, Device and Cosmetic Act.I have not been convicted of an offense similar in nature to those crimes listed under paragraphs 2, 3 or 4 above under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law Pennsylvania.I understand that statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

Signature

Date

Example: 01/01/1950