Office Use Only: Background check req’d Date completed:
FOCUS
VOLUNTEER APPLICATION
I would like to volunteer for: ESS Respite
__ Acworth __ Alpharetta __ Cumming __Chamblee __ Conyers __ Marietta __ Snellville
Name Age (If under 18)
Address
City State Zip
Phone (H) (W) (C)
Group associated with E-mail
Have you volunteered with FOCUS before? Yes No. If yes, which program?
Please describe any experience with children with disabilities
Employer or School Length of employment
Job Title Hours worked
Please list any medical conditions:
Emergency contact name: Phone: Relationship
Have you been arrested or charged with a crime in the past ten years, other than a minor traffic offense?
Yes No. If yes, please describe
List two personal references and phone numbers:
1.
2.
In connection with my voluntary involvement in activities undertaken, and with the participation and support of Families Of Children Under Stress (FOCUS), a nonprofit charitable organization, I hereby agree, for myself, my heirs, assigns, executors, and administrators to release and discharge FOCUS, its officers and directors, employees, agents and volunteers from all claims, demands and actions for injuries sustained to my person and/or property as a result of my involvement in such activities, whether or not resulting from the negligence of FOCUS or anyone working on behalf of FOCUS, and I agree to release and hold FOCUS, its officers and directors, employees, agents and volunteers harmless from any cause or action, claim, or suit arising therewith. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at my own risk, and that I have read the foregoing terms and conditions of this release. Furthermore, I grant permission for photographs, video and quotations from me during my involvement with FOCUS to be used to further promote FOCUS and volunteerism.
I hereby confirm, represent and warrant that I have never been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith.
Signature Parent/Guardian’s signature required, if under 18 Date
Families Of Children Under Stress
3825 Presidential Pkwy., Suite 103* Atlanta, GA 30340 * Telephone: (770)234-9111
Fax: (770) 234-9131 * web: www.focus-ga.org * email: focus-ga@mindspring.com