New Volunteer Intake

First Name	* Required
Middle Name
Last Name	* Required
Suffix
Address	* Required
Apt/Unit
City	* Required
State	* Required
Zip	* Required
Home Phone	* Required
Work Phone
Cell Phone

Email Address (This will also serve as your username.)	* Required
Please choose a Password	* Required

Date of Birth	* Required

Emergency Contact Information (Please include Name, Relationship, and Phone Number.)	* Required
Please check yes or no to the following:
Do you use illegal drugs?	* Required
Have you ever been convicted of a criminal offense?	* Required

Have you ever been charged with neglect, abuse, or assault?	* Required

Has your driver's license ever been suspended or revoked in any state?	* Required


Please describe your education and work history:	* Required

Please describe any previous experience working with individuals with intellectual or developmental disabilities:	* Required

What special skills or talents do you hope to share with the Disability Action Center?	* Required

Why do you wish to volunteer with the Disability Action Center?	* Required

Please Provide two references with whom we can verify your personal character. Include Name, Address, and Phone numbers:
Reference 1:	* Required


Reference 2:	* Required
PLEASE READ BEFORE SIGNING:
Some of the information that I have provided may be verified, and I give permission to The DAC to check my references. In the course of volunteering for The DAC, I may be dealing with confidential information and I agree to keep said information in the strictest confidence. In relationship between The DAC volunteers is an “at will” arrangement, and that it may be terminated at any time without cause by either the volunteer or The DAC. I hereby agree to release, discharge and hold harmless The Disability Action Center, its officers, agents, its director and employees of and from all causes, liabilities, damages, claims or demands on account of any injury or accident arising out of my attendance and participation as a volunteer with The Disability Action Center. I will respect the rights, dignity and worth of the members, other volunteers, parents, officers, board members and friends of The DAC. I will treat everyone equally regardless of sex, ethnic origin, religion or ability and be a positive role model. My language, manner and presentation will demonstrate high standards. I will display control, respect, dignity and professionalism to all involved with The DAC. I will not drink alcohol, smoke or take illegal drugs while representing those involved with The Disability Action Center. I will refrain from any form of personal abuse towards our members, volunteers, officers, board members and parents, including inappropriate or unwanted sexual advances on others, verbal, physical and emotional abuse.
I understand that if I violate this Code of Conduct I will be subject to a range of consequences, up to and including being prohibited from volunteering for The Disability Action Center.	* Required
Date of Agreement (today's date):	* Required

Please leave this checkbox blank