Family and Community Volunteer Application

Family and Community Volunteer Application

Family and Community Volunteer Application

Family and Community Volunteer Application

Family and Community members who have been convicted of Child Abuse or Neglect, or are on any Sex Offender Registry, may not volunteer in a Head Start classroom. Family and Community members who have been convicted of a felony involving harm, threatened harm, or illegal drugs may not volunteer in a Head Start classroom. Family and Community members convicted of a misdemeanor involving harm, threatened harm, or illegal drugs within the previous 5 years may not volunteer in a Head Start classroom. If you may not volunteer in a Head Start classroom, we will give you other options or volunteer opportunities.

Volunteer Name *

Volunteer Name

First

First

Last

Last

Middle Initial *

Maiden Name or Other Names Known By

Gender *

Male

Female

OtherOther

Date of Birth *

Phone *

Race *

Asian or Pacific Islander

American Indian or Alaskan Native

Black

White

OtherOther

Language(s) spoken or written: *

English

Spanish

Sign Language

OtherOther

Address *

City *

State *

Zip Code *

Location(s) you want to volunteer

Administrative Office

Bangor

Benton Harbor (DEC)

Cassopolis

Decatur

Decatur Kitchen

Dowagiac

Gobles

Gray Street Office

Mattawan

New Buffalo

Niles Bell

Niles Brandywine

Paw Paw Cedar Street

River of Life

Riverview

Sawyer

SMC Dowagiac

South Haven

Spinks

Watervliet

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Name

First

First

Last

Last

Emergency Contact Phone *

Relationship to Volunteer * SpouseMotherFatherBrotherSisterAuntUncleGrandmaGrandpaFriendOther Relationship to Volunteer

Allergies *

Hospital Preferred *

Volunteer Agreement I agree to allow Tri-County Head Start's Human Resources Department to complete a background check using the Internet Criminal History Access Tool (ICHAT) and Sex Offenders Registry (SOR). I agree to provide proof of COVID-19 vaccination or exemption status to Tri-County Head Start's Human Resources Department. I am aware that abuse and neglect of children is against the law. I have read and understand Tri-County Head Start's Protective Services Referral Policy. I am aware that all staff and volunteers are required by law to immediately report suspected abuse and neglect to Children's Protective Services.

Volunteer Signature *

Clear

Date *

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