ONE TO ONE Volunteer Application (3 pages)
1. Date: ________________
2. Name (Last, First, Middle): ________________________________________________________
3. Mailing Address: ______________________________________________________________
Physical Address: ______________________________________________________________
E-mail Address: ________________________________________________________________
4. Home phone: ______________________ 5. Work phone: _______________________
Best way to contact you: ________________________________________________________
6. Place of employment: ___________________________________________________________
7. Date of birth: _______________________________
8. Marital Status: Single Married Divorced Widowed Living w/ partner
9. Spouse’s or partner’s name: _______________________________________________________
10. Names & ages of children ( if any) __________________________________________________
_______________________________________________________________________________
11. How long have you lived in this community? __________________________________________
12. What languages do you speak? ______________________________________________________
13. Do you anticipate any job/family/location changes in the next 18 months? ___________________
If yes, please explain: _____________________________________________________
14. Do you own a car? ____________ Drivers License #: _________________________________
15. Have you ever been convicted of a criminal offense? ____________________________________
If yes, please explain: _____________________________________________________
16. How did you hear about the program (circle all that apply):
Radio Newspaper TV Board member Current BB/BS
17. Why did you apply to be a volunteer at this time?
Volunteer Policy and Profile
One to One is a non-profit organization designed to help children who have shown a need for a strong relationship with an interested, adult friend. Our goal is to make the best “match” possible - to pair an adult with similar interests and needs as the child.
Interviews are designed to establish a profile of you and your interests. This profile shall be used by the agency to best match you with a child who suits you. Except for parents and/or guardians with a direct responsibility for a child who has been pre-screened and is actively being considered for a match with you, all elements of your profile will be kept in the strictest confidence. Prior to any assignment to a child, a similar profile of them and their family will be discussed with you to insure that your desires will be respected.
In determining whether an applicant may be considered for a match and what information shall be communicated to each party involved in any prospective match, due consideration must be given to a variety of factors in the health, personality, and behavior of each individual which may have a significant effect upon the relationship, and which, if revealed at a later date, might effect it adversely. Relevant information shall be provided to each party, and any party has the right to refuse to enter into the match upon the information so communicated.
I understand that One to One reserves the right and has total discretion to decline my application if in the judgment of the professional staff and/or governing board it is felt that this type of volunteer service is not appropriate for me at this time.
I also give permission, if I am accepted as a mentor, for my name to be used for promotional purposes for One to One (ie. in the newsletter or a “thank you” to the newspaper).
Signature of applicant: _________________________________________ Date: ____________________
Authorization for release of confidential information
I understand it will be necessary for One to One to investigate my background and to check my references. I hereby give consent for this information exchange and authorize other parties to release any information requested of them. I understand that the parties to be contacted could include employers, courts, Motor Vehicles Division, law enforcement in any state, social services, counselors, or any other parties who One to One deems necessary.
Signature of applicant: ___________________________________________________________________
Please list the names and complete address of four people that can attest to your ability to be an adult mentor. Relatives and current boyfriend/girlfriends are not allowed.
Name of reference Mailing Address
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
If I become a volunteer in the One to One program, I fully understand that I am expected to have consistent contact with the child with whom I am matched.
I understand and agree that I must show proof of automobile insurance protection for myself and the child to protect against bodily injury.
I knowingly understand and agree to release from liability and hold harmless One to One for any personal injuries or property damage I may receive or suffer while in the course of my activities as a volunteer.
I certify that my statements on this application are true, complete, and correct to the best of my knowledge.
Signature of applicant: ________________________________________________________________
Automobile Insurance Verification
**We need proof that you have automobile insurance. Please include a copy of your current insurance card.
Full liability, Colorado Personal Injury Protection coverage, and Uninsured and Underinsured Motorist coverage written to the same limits as the Bodily Injury coverage. Bodily Injury/Property Damage must be at least the state minimum of 25/50/15.