Volunteer Application

Achieva resources VOLUNTEER Advocacy Services

Volunteer Application Form

Part 1 - Personal History

A. General History

* Indicates required field

Name *

First

Last

Current Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Date of Birth *

Gender *

Male Female

Emergency Contact *

Emergency Contact Phone Number *

Emergency Contact Address *

Line 1

Line 2

City

State

Zip Code

Country

B. Transportation

Do you have a car with valid insurance? *

Yes No

Have you ever been charged or convicted of a DUI or reckless driving traffic offense? *

Yes No

Drivers License State and Number *

If charged for DUI or reckless driving please explain *

D. Education/Training Experience

Did you graduate from high school? *

Yes No

Other Educational/Training programs completed *

Name of School *

E. Legal History

Have you ever been arrested, indicted, or charged with a misdemeanor or criminal offense? *

Yes No

Have you been convicted of a felony within the last 7 years? *

Yes No

Have you been convicted of a misdemeanor or criminal offense? *

Yes No

If convicted please explain *

Part 2 - Motivation and Life History Information

Please answer the following questions in paragraph form

Write a short summary about your interest in volunteering. *

Part 3 - Personal References

Achieva Resources requires three personal or professional references to complete the Volunteer Application. Please print the names, addresses, zip codes and telephone numbers of three people who have known you for a minimum of two years. The references need to be individuals who can address how well you relate to elderly and/or incapacitated persons and how well you can fulfill the responsibility of being a Achieva Resource Volunteer Advocate. Please do not include relatives. Achieva Resources staff will contact the references by mail.

Reference 1 *

First

Last

Reference 1 Relationship *

Reference 1 Length of acquaintance *

Reference 1 Phone Number *

Reference 1 Address *

Reference 2 *

First

Last

Reference 2 Relationship *

Reference 2 Length of acquaintance *

Reference 2 Phone Number *

Reference 2 Address *

Reference 3 *

First

Last

Reference 3 Relationship *

Reference 3 Length of acquaintance *

Reference 3 Phone Number *

Reference 3 Address *

Part 4 - Affirmation and acceptance

I hereby affirm that all the answers on the above Volunteer Application for the Volunteer Advocate Program are true to the best of my knowledge. I hereby authorize the Volunteer Advocate Program and to investigate my background to determine my fitness as a potential Volunteer Limited Guardian. I understand that the information requested in this application will be used only for the purpose of determining my suitability as a volunteer.

Furthermore, I understand that after the successful completion of my training, I will be expected to serve a minimum of one year or for as long as the incapacitated person's case to which I am assigned is being supervised by the Volunteer Advocate Program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the Volunteer Advocate Program as soon as possible.

I am aware of the sensitive and confidential nature of the official documents, reports and other materials I will examine in my capacity as a Volunteer Advocate. I promise that I shall hold all pertinent information in strict confidence. I will only discuss the contents of these materials with those persons who are parties to the case and their legal representatives or with persons or organizations that may be consulted for professional knowledge or expertise. I will not remove any written records from the Volunteer Advocate Program office without expressed permission. I accept full responsibility for maintaining the confidential and private nature of all records and information. I understand that I am personally responsible and liable for any violation of this statement.

Electronic Signature *

First

Last

Electronic Signature Date *

Electronic Signature Email *

Submit

Achieva Resources Corporation, Inc., P.O. Box 1252, 800 Mendleson Drive, Richmond, Indiana 47375
Phone: 765-966-0502 Fax: 765-962-3179