Form Center

Step One

Are you a: *
1. New volunteer to SRDA
2. Returning volunteer to SRDA
How did you hear about the volunteer program?*
Today's Date*
Today's Date
Are you a current client of SRDA?*
1. Yes
2. No
Which Department?
Are you a past client of SRDA?*
1. Yes
2. No
Why do you want to volunteer?*
Are you a veteran?*
1. Yes
2. No
What is your ethnic/racial background? (Check all that apply)*
1. White
2. Hispanic
3. Black or African American
1. Asian
2. American Indian/Alaska
3. Native, Hawaiian/Pacific Island
Volunteer Identification - Information provided in this section is used for identification purposes only.
Legal Name*
Date of Birth*
Date of Birth
Gender*
Street Address 1*
Street Address 2
City*
State*
Zip Code*
Home Phone*
Cell Phone
Work Phone
E-mail*
Do you have a Commercial Driver License (CDL)?*
1. Yes
2. No
Doctor's Name*
Preferred Hospital*
Allergies (Please separate by commas)*
Any Recent Illness or Conditions?*
Insurance Coverage (Check all that apply)*
1. Liability
2. Comprehensive
3. Collision
Emergency Contacts and/or Beneficiary – Who can we contact in case of an emergency?
First Name*
Last Name*
Street Address*
City*
State*
Zip Code*
Home Phone*
Cell Phone
Work Phone
Relationship*
Would you like to add a Secondary Emergency Contact?*
1. Yes
2. No
First Name
Last Name
Street Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Relationship
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Step Two

Step Three

Employment History
Company
Phone
Street Address
City
State
Zip Code
Job Title
From
From
To
To
Would You like to Add Another Job to Employment History?*
1. Yes
2. No
Company
Phone
Street Address
City
State
Zip Code
Job Title
From
From
To
To
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Releases and Statements

Background Check Release – For SRDA Volunteer Positions Only
Advisement
The elderly are a potentially vulnerable, high-risk group. SRDA asks that you provide authorization for a criminal record check prior to your potential volunteer placement. The criminal record check is conducted via a secure website. It is returned electronically to the SRDA administrative staff and becomes a part of your volunteer record.
Acknowledgement
I have read the above statement and I understand SRDA’s requirement for a criminal record check prior to further consideration of my application for volunteer placement. I understand that I am being asked to voluntarily provide information. I further understand that failure to provide the information will disqualify me from further consideration concerning the volunteer position for which I might apply
Opt Out
1. I decline
Drug and Alcohol Testing – Only for Transportation
Per the Department of Transportation (CDOT) regulations, drug and alcohol testing will be required for all volunteers that drive a SRDA vehicle and/or transport any SRDA client in their own vehicle. Volunteers who meet these criteria will be subject to testing once training is completed as well as periodic quarterly random drug testing. (Federal Transit Administration (FTA) regulation 49 CFR Part 655)
Opt Out
1. I decline
Driving Record Release – For SRDA Volunteer Positions Only
Driving records may be obtained as part of SRDA’s evaluation of my volunteering. The reports may be procured to provide an assessment of my insurability under the Company’s insurance coverage’s. By signing this disclosure, I hereby authorize SRDA to procure such reports and additional reports about me, as appropriate to evaluate my insurability or for other permissible purposes
Opt Out
1. I decline
Photo Release
I hereby agree to allow SRDA to take my photograph while volunteering for SRDA; I grant ownership of any such photographs to SRDA and specifically release any rights or claims to same. These photographs may be used for advertising, communications, and/or commercial purposes.
Opt Out
1. I decline
Release of Liability
I agree not to hold SRDA liable in the case of injury or accident.
Opt Out
1. I decline
Confidentiality Statements – Your commitment to SRDA and its clients
We have a policy of strict confidentiality. Names, specific conditions and/or other personal details are to be held in strict confidence. By all means, share the stories, the successes and the warmth – but please leave out the personal details. This includes detailed information about clients, other volunteers, donors and staff.
Agreement
I assert that the information provided above and on previous page(s) is accurate to the best of my knowledge and I agree with the terms stated herein. I understand that declining any of the above information needed may disqualify me from further consideration concerning the volunteer position for which I am applying for.
Printed Legal Name*
Date*
Date
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Criminal Background Questionnaire

Have you ever been charged, arrested, or convicted of a felony or misdemeanor that is not sealed or expunged, regardless of the disposition of any such matter? Your answer to this question will only be used to the extent it is reasonably related to the position for which you are being considered. *
1. Yes
2. No
Give a short explanation of the incident in the space below. Please indicate the date, nature and place of the incident, the disposition of the allegations, and your employer at the time, including your employer’s name, address, and telephone number. We will conduct an individualized assessment of its relevance to the position for which you are applying.
Printed Legal Name*
Date*
Date
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Volunteer Application

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Releases and Statements

Criminal Background Questionnaire

Statement of Compliance

Senior Resource Development Agency

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