Volunteer Application Step 1 of 6 16% StatusActiveInactiveRejectedAbout YouLegal Name* First Last Nickname / Name You Go ByAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Primary Phone*Primary Phone Type*CellHomeWorkSecondary PhoneSecondary Phone TypeCellHomeWorkDate of Birth*Why is this required?The Montrose Center conducts criminal background checks on most volunteer applicants. Access to these records requires an accurate date of birth. If records cannot be accessed with this information, additional data may be required such as Social Security number.Social Security #Optional. We may ask you to furnish this information at a later date. More About YouEmergency Contact Name* First Last Emergency Contact Phone*If you speak languages other than English, please specify:Fluency Speak Read Write Orientation: How do you identify?LesbianGayBisexualQueerStraightGender: How do you identify? Cisgender Woman Cisgender Man Transgender Woman Transgender Man Genderqueer/Nonbinary Intersex Which pronouns do you use for yourself?He/him/hisShe/her/hersZe/hir/hirsThey/them/theirsAny of the aboveSomething elseWhy do we ask about orientation/gender?Both fields are optional. The Montrose Center does not discriminate on the basis of gender, orientation, or for that matter, race, ethnicity, nationality, age, religion, or disability. All personal information is kept confidential. This information supports us in acknowledging all of our volunteers accurately and respectfully. It also helps us determine which communities require additional outreach with regard to volunteer opportunities. EmploymentWhat is your employment status?*Employed full-timeEmployed part-timeRetiredPermanent disabilityShort-term disabilityUnemployedWhat is the name of your employer?*Does your employer participate with Dollars for Doers or any other volunteer grants?YesNoI don't know.Professionally, what kind of work do/did you do?*Have you, your partner/spouse or any member of your family received counseling, treatment, case management or housing assistance at the Montrose Center within the last 24 months?*YesNoVolunteer ExperienceHow many years' volunteer experience do you have?*01-33-55 or moreBriefly describe your most recent volunteer experience.Skills & EducationAre you a student?*YesNoStatus?*Full time (12 hours/week or more)Part time (9 hours/week or less)What is the name of the school and specific program you are enrolled in?(e.g., University of Houston - Graduate College of Social Work)What is the highest level of education you have achieved so far?*Some high schoolDiploma / GEDProfessional CertificationSome collegeAssociate DegreeBachelor DegreeMaster DegreeDoctorate DegreePlease list any licenses, certifications or professional credentials that you maintain:Describe any hobbies, special skills, talents or interests that you would like to share: AvailabilityHow many hours per week would you like to volunteer (average)?*Please indicate your general hours of availability below. We understand that this may change. Schedule of Availability: MON TUE WED THU FRI SAT SUN StartAMPMEndAMPM StartAMPMEndAMPM StartAMPMEndAMPM StartAMPMEndAMPM StartAMPMEndAMPM StartAMPMEndAMPM StartAMPMEndAMPM Areas of InterestPlease check all that you might be interested in. This will in no way limit your potential assignment, nor does it guarantee an assignment in those areas.General Center Support Cyber Center Attendant Technology Committee Equal Grounds Café Attendant Equal Grounds Café Committee Front Desk Specialist (must take Crisis Intervention training) Clerical support Data entry Building maintenance and construction Landscaping/ beautification Disaster Relief Volunteer Events & Fundraising Staff information table at outreach events Represent the Montrose Center at fundraising events Write thank-you letters Invite your friends/contacts to events Conduct tele-ask campaigns Lead building tours Behavioral Health & Wellness Integrative Wellness Coach Wellness Class Instructor or Educator (ex: walking group, nutrition ) Support Group Facilitator Case Management Clerical Assistant Quarterly Advisory Panel Volunteer Veterans Community Leader Details:*Subject: Days/times interested: Qualifications: Senior Services Montrose Diner Lunch Server Montrose Diner Host Daytime Activity Leader Advocate (outreach and education about senior services) Details:*Subject: Days/times interested: Qualifications: Youth Services Hatch Youth Facilitator Hatch Prom & special events support Youth outreach (must be LGBT age 18-25) Evening Activity Leader (Tue/Fri/Sun) Details:*Subject: Days/times interested: Qualifications: Student Internship Undergraduate Intern Graduate Intern Semester / Year*Total Number of Hours to Complete*MSW and LPC candidates may not use this application for field placement consideration. Please contact your institution for information about placement with the Center. Have you ever been convicted of or charged with a felony resulting in a disposition other than acquittal or dismissal?*YesNoPlease explain:*Have you ever had any licensing board or professional ethics body require you to surrender your license or found you guilty of professional misconduct, unprofessional conduct, incompetence or negligence?*YesNoPlease explain:*Have you ever had your professional license, professional liability insurance or bond denied, revoked, not renewed or suspended?*YesNoPlease explain:*Are there any charges or complaints pending against you by any licensing board or professional ethics body for professional misconduct, unprofessional conduct, incompetence or negligence?*YesNoPlease explain:*Are you aware of any circumstances that may result in any claim or suit being made against you regarding your current or past professional conduct?*YesNoPlease explain:*Has any professional liability claim or suit ever been made against you for your professional conduct?*YesNoPlease explain:*How did you learn about the Montrose Center's volunteer program?FriendFlyer / poster / handoutPrint advertisementRadioFacebookthe Montrose Center / Hatch Youth websiteCourts / criminal justice systemDo you hold any beliefs or life experiences that may limit your ability to work with LGBT persons, elders, youth, suicidal persons, or survivors of sexual assault or domestic violence?*YesMaybe / I'm not sureNoPlease explain:* STANDARD AGREEMENTS Please carefully read and click next to each statement to signify your agreement.Use of Information*I understand that this information in this application will be used, in part, to determine my eligibility for a volunteer position with the Center.Authenticity*I have read and understand the above information. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if accepted as a volunteer, falsified statements contained on this application may be considered grounds for dismissal. I authorize investigation of all statements contained herein and contact of the references listed above to give you any pertinent information they may have. I release all parties from all liability for any damage that may result from furnishing same to the Center.By entering your name and today's date below, you further indicate that you agree with the above statements, and authorize Montrose Counseling Center, Inc. to process this application.Name* First Last Today's Date* Date Format: MM slash DD slash YYYY
