The Autism Council of Rochester, Inc.
VOLUNTEER APPLICATION
Thank you for your interest in joining The
Autism Council of Rochester, Inc. Volunteers are the key to
meeting the needs of individuals with Autism &
other developmental disabilities.
Please read these instructions, complete the
application and return it to the Volunteer Coordinator of the agency.
Incomplete
applications will be returned.
Applicants must be at least 18 years of age to
apply, be of good character, with no felonies or legal convictions.
The council is looking for people with great
communication skills and a desire to work with individuals who have Autism &
other developmental disabilities.
We hope you will
join our agency in the important and rewarding activities of assisting our
community members!
If you have
questions, or if we can be of any help in the application procedure, please call
(585) 413-1681.
The Autism
Council of Rochester, Inc. mission is to be the community leader in providing
high quality and individualized, person centered, community integration services
and supports to youth, young adults, and parents of individuals with Autism
Spectrum Disorder (ASD) and other developmental disabilities
To be the
agency of choice, in the selection and delivery of specialized services for
individuals with Autism Spectrum Disorder (ASD) and other developmental
disabilities.
We provide
individualized person centered community integration planning and training
(Transition Services) to youth and young adults with ASD and other developmental
disabilities. We interface with
community providers and other agencies to help build the future work, school,
and or college plans for youth and young adults with ASD and other developmental
disabilities.
We provide Autism Spectrum
Disorder awareness training to the community, service providers, educators and
medical rescue personnel.
Application Procedure:
1. Complete the application and
return it to: Volunteer Coordinator, Al Sigl Center, 1000 Elmwood Ave. –
2.
Include two character references
for question 37.
3. A background may be done using
Law Enforcement files.
Violations do not
always result in rejection. Intentional omissions will automatically disqualify an applicant.
Volunteer Application Form
All fields are required to be filled out accurately prior to becoming a
volunteer.
Incomplete applications will not be processed.
Please Print Name, Address and Telephone Numbers:
Last Name: _________________________________________________________________
First Name: _________________________________________________________________
Middle Name: _______________________________________________________________
Mailing Address: _____________________________________________________________
Apt or Suite Number: __________________________
City:
Home Telephone Number: __________________ Cell Telephone: ______________________
Pager Telephone Number: ___________________ Business Telephone:
__________________
E-mail Address: ______________________________________________________________
Demographic Information:
Date of Birth: _______________________________
Name of person to contact in case of an emergency:
Last Name: ________________________________
First Name: ________________________________
Relationship: _______________________________
Telephone Numbers to call: Day: ________________ Evening: ___________________
Physician’s Name: ____________________________________________________________
(Please print)
Telephone Number: (______)______________________
Information about your education:
(Please fill in based on your current level of education.)
I have completed:
*If
applicable, please list the college that you are attending now:
_________________________
If applicable, please denote what academic year you are in currently:
______ Freshman ______ Sophomore ______ Junior _______ Senior
I have completed or am finishing
I need volunteer hours for school/college credit: _______ If yes, how many?
_________
Please list the name of the college/university you
graduated from:
_____________________
Information about your employment:
Employer: ___________________________________________________________________
Position: ____________________________________________________________________
Information about your health:
Is there any health reason that might limit your ability to volunteer? ______
Yes _____ No
If yes, please describe:
__________________________________________________________
Please check off the infectious illnesses you have had:
______ Measles ______ Mumps _______ Rubella _______ Chicken Pox ______
Diphtheria
______ Polio ______ Tetanus _______ Whooping Cough
Please check the infectious illnesses you have been immunized for:
______ Measles ______ Mumps _______ Rubella _______ Chicken Pox ______
Diphtheria
______ Polio ______ Tetanus _______ Whooping Cough
How did you hear about volunteering at The Autism Council of
______ A Current Volunteer ______ Council’s Website ______ Council
Employee
______ Newspaper ______ TV ______ Work ______ School/College
______ Other…please explain: ___________________________________________________
Information about your volunteer interests:
Please describe in detail why are you interested in volunteering here at the
Council?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Information about your interests/skills/experience and availability:
Would you prefer to volunteer: ______ Directly with children ______ Directly
with families
______ In support areas…please denote which specific area:
___________________________
Please list your experiences or skills that relate to the preference indicated
previously:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list your current volunteer roles with location (if any) and list your
previous volunteer roles:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please circle the most appropriate day and shift that you would be available to
volunteer:
Mornings:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Afternoons:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Evenings:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Are you available/interested in supporting youth at Special Events (Recreation,
Social or Programs)
____ No ____ Yes ____ Morning ____ Afternoon ____ Evening ____ Weekend
Are you available/interested in assisting with special projects such as mailings
or office work?
____ No ____ Yes ____ Morning ____ Afternoon ____ Evening ____ Weekend
References:
Please print the COMPLETE
mailing addresses of three people (minimum) we may contact (excluding
relatives and roommates)
who have known you for more than two years. Local references preferred.
Name: _________________________________________ Relationship:
___________________
Address:
Telephone: (____)________________________________
Name: _________________________________________ Relationship:
___________________
Address:
Telephone: (____)________________________________
Name: _________________________________________ Relationship:
___________________
Address:
Telephone: (____)________________________________
The Autism Council of Rochester, Inc. reserves the right to conduct state and
federal
background checks.
Have you ever been arrested for conducting or attempting to conduct a felony or
sexual offense?
_____ Yes _____ No
If yes, please list the date(s) of the arrest(s) and any facts and circumstances
surrounding the
Arrest.
If you are subsequently arrested for conducting or attempting to conduct a
felony or sexual offense during the course of your volunteer services at The
Council, you agree to notify Volunteer Services Coordinator. Failure to do so
will result in termination of your services.
__________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever been convicted, plead no contest, or plead guilty to a felony or
misdemeanor?
_____ Yes _____ No
For Office Use Only:
Received: __________
Entered: __________
Reference Check: __________
Criminal Check: __________
Read and Sign This Section at The End:
Volunteer Privacy Information and Release
Authorization
Please read the following carefully
Application information
I certify that all information in this application is
true and complete.
I understand that any false information or omission
may disqualify me from further
consideration for volunteer service and may result in
my dismissal, if discovered, at a
later date.
References
I understand that The Autism Council of Rochester,
Inc. requires information from me to
evaluate my qualifications for volunteer service.
I authorize and release personal references,
employers (past and present), and, if
necessary, other applicable entities to answer
questions in regards to volunteer work,
employment, ability, character, medical and emotional
background and, if applicable,
driving history.
Background investigation
I understand, in consideration of my application, a
background investigation will be
conducted.
I understand this investigation may include, but is
not limited to, a criminal background
check in the files of any Federal, state or local
justice agency, driving history,
performance of medical examinations, drug screening
or reference verification.
I authorize The Autism Council of Rochester, Inc. and
associated entities (collectively
ACR) to conduct the background investigation and
release The Autism Council of Rochester, Inc. from
responsibility for this investigation.
I understand the requested information is for the
sole purpose of gathering accurate
information for volunteer services.
*** Important
Please Sign
I have read and understand the above and by my
signature consent to these statements.
__________________________________________
______________________
Applicant Signature Date
PERSONAL PRIVACY PROTECTION
The information you provide on
this application is requested to meet
the agency’s legal obligations.
It will be used in accordance with
Section 96 of the Personal
Privacy Protection Law. The information
will be
maintained by the Volunteer Coordinator / & or
Human Resource Department.
NON-DISCRIMINATION
The Autism Council of Rochester,
Inc. does not discriminate on the basis of age, race, creed, color, national
origin,
gender, religion, sexual
orientation, marital status, genetic predisposition
or carrier status, or disability
in paid or volunteer employment or provision of services.
MAIL THIS COMPLETED FORM TO:
Volunteer Coordinator
The Autism Council of Rochester, Inc.
Al Sigl Center, 1000 Elmwood Ave.,