Volunteer Application

I. Volunteer Information

Name*

Address (City, State, Zip)*

Your Email*

Home Phone Work Phone Mobile Phone

II. Background

1, Education* High School College Technical School

2. Professional Certifications/Licenses (electrical, mechanical, plumbing, etc.) (999 chars left)

3. Any qualities, experience, interests or special training (999 chars left)

4. Current Employment (999 chars left)*

III. Times Available to Volunteer

Add times available for each day of the week

IV. References

Reference #1: Name and email*

Reference #2: Name and email*

V. Emergency Contact

Contact Name*

Contact Relationship*

Contact Address and Phone*

Vi. Questions of Record

1. Do you have any vehicular moving violations in last 36 months?* Yes No

If yes, explain

2. Do you have any vehicular accidents in last 36 months?* Yes No

If yes, explain

3. Do you have any suspension of driver’s license in last 36 months?* Yes No

If yes, explain

4. Do you have any DUI or DWI in last 60 months?* Yes No

If yes, explain

5. Do you have any felony or misdemeanor convictions?* Yes No

If yes, explain

6. Do you have any committed or confirmed child or adult abuse?* Yes No

If yes, explain

7. Are you eligible for employment in the United States?* Yes No

If no, explain

8. Do you have any relatives or friends employed or served at SLI?* Yes No

If yes, explain

9. Have you ever been asked to resign from a job?* Yes No

If yes, explain

SLI Applicant Authorization to Release Information

(To be used regarding applicants for pre-employment references and volunteer screening)

I authorize SLI to contact any company, institution, law enforcement agency, state agency, bureau or individual it deems appropriate to investigate my employment history, job performance, background, qualifications, driving record, and other relevant information, if job related. I give my full consent for all contacted persons including former employers to provide the information concerning this application. I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to the Company.

SLI currently verifies information with:

Kansas Bureau of Investigation
KDADS Nurse Aide Registry
Adult and Child Abuse and Neglect - Department for Children and Families
Motor Vehicle Report
Topeka Municipal Court
KDADS Health Occupations Credentialing
Office of Inspector General
Shawnee County Court Records
KDOC Kansas Adult Supervised Population Electronic Repository
Other local, state and national databases and public information systems

Enter Your Full Name*

Maiden Name and/or any other names currently or formerly known by

Use your mouse, trackpad or touch device to enter your signature*