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Volunteer Application

Personal Information

 
 
 
 


Address

 
 
 
 
 


Emergency Contact

 
 
 
 
 


Background Information

 
 
 
 
 


 Help with special events Short-term projects Part-time commitment Full-time commitment


References
(For part-time and full-time candidates only)

 
 
 
 
 

 
 
 
 
 

 
 
 
 
 


Volunteer Interest



 Website School SCI Team Member Co-worker Public event Friend/family Flier/poster Other


 To get involved in helping my community To build job skills To fulfill school requirement To fulfill DET requirement To fulfill TANF requirement Other
 
 

       
     


Agreement

I certify that I have and will provide information throughout the selection process, including on this application, that is true, correct and complete to the best of my knowledge. I agree to serve any client who is assigned regardless of race, sex, creed or national origin. I understand that I will not be paid for my services as a volunteer.


Self Identification

Race/ethnic, gender & disability

Privacy Statement

You are requested to furnish this information to aid the federal judiciary in reporting on equal employment opportunities. This sheet will not be provided to decision-makers who are evaluating your application. This information will be used in planning and monitoring fair employment practices programs. Furnishing this information is voluntary. Failure to do so will have no effect on your application for employment.

Specific Instructions

Please identify your gender and whether or not you have a disability. The categories below are designed to identify your basic racial and national origin category. If you are of mixed racial and/or national origin, identify yourself by the category with which you most closely identify yourself. Mark the box next to the appropriate category.

Demographics

 Female Male
 No Yes


Choose only ONE of the following categories:

 White Black/African American Hispanic/Latino Asian American Indian/Alaskan Native (Native American) Native Hawaiian/Pacific Islander Other


CORI Request Form

The Codman Square Health Center has been certified by the Criminal History Systems Board for access to conviction data and pending criminal case data. As an applicant/employee for the position of  , I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information submitted on this form is correct to the best of my knowledge.

I understand that a criminal record check will be conducted upon my application for a volunteer position, and may periodically be requested during my volunteer engagement. Pending receipt of my criminal record, Codman Square Health Center may, at its discretion, provide me with a volunteer orientation program and/or a temporary position, neither of which would involve direct or indirect client contact or access to client files. I understand that my continued volunteering is subject to the results of my criminal record investigation and that I may be terminated from volunteering based on the criminal record information, which is received, and which does not comply with the criminal record policy of Codman Square Health Center.

Applicant/employee information

 
 
 
 
 

 

Partners: DotWell | Dorchester House Multi-Service Center
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Codman Square Health Center · 637 Washington Street, Dorchester, MA 02124 · (617) 825-9660
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