Adult - Class "A" Volunteer Application (Age 18 And Above)

Special Olympics Connecticut, Inc.

ADULT

- CLASS “A” VOLUNTEER APPLICATION

(Age 18 and above)

)

PART I

-

GENERAL INFORMATION (Please use ink and PRINT all information

LAST NAME: ________________________________________FIRST NAME: _____________________________MDDLE NAME:_________________________________

MAILING ADDRESS (No P.O. Boxes): _________________________________________________________________________________________________________

CITY: ____________________________________________________________

STATE: ______________________________

ZIP: _____________________

EMAIL:________________________________________________________ LENGTH OF TIME AT CURRENT ADDRESS: _______________________________________

PHONE: (HOME) ___________________________________ (CELL)__ _____________________________________ BIRTH DATE ________________ ____(required)

EMPLOYER/SCHOOL/ORGANIZATION:____________________________________________________ OCCUPATION:__________________________

(required for background check, this information is confidential)

SOCIAL SECURITY NUMBER: ______________-____________-_________________________

PART II

-

PROTECTIVE BEHAVIORS

Yes

No

(Aged 18 and above -

)

must be completed every 3 years at

Have you completed the protective behaviors program?

…………………………………………………………………………………………...…… 



Date Completed _______/_______/________

PART III

-

VOLUNTEER DUTIES Please check all that apply to your status with SOCT



COACHING



FINANCE



MEDICAL SERVICES



VOLUNTEER MANAGEMENT

GAMES DIRECTOR

DEVELOPMENT

PUBLIC RELATIONS

LOCAL PROGRAM COMMITTEE









SOCT BOARD MEMBER

SPORTS MANAGEMENT

OVERNIGHT CHAPERONE

LOCAL COORDINATOR









UNIFIED SPORTS ® PARTNER

 OTHER _____________________________________________________________________



Indicate the Local Program that you’re a part of: Local (required)______________________________________________________________________

PART IV

-

BACKGROUND INFORMATION (This section MUST be completed

. All information is confidential.)

Yes

No

Do you use an illegal drug that would affect your ability to perform any of the duties listed above? ................................................................................ 



Have you ever been convicted of a crime? .......................................................................................................................................................................................... 



Have you ever been reported to the Department of Children and Families or a comparable child welfare agency with a finding of abuse or

neglect against you? .................................................................................................................................................................................................................................. 



Has your drivers’ license ever been suspended or revoked as a result of a moving violation in any state? ....................................................................... 



a written explanation.)

(If you answered “yes” to any of the above questions, please attach

PART V

-

DRIVER’S LICENSE INFORMATION

If you currently transport athletes, drive other vehicles for SOCT, or may do so in the future, you must

provide driver’s license information, if not please leave this blank

Do you have a valid driver’s license? Yes

 No

If yes, License Number ___________________________________State Issued___________________

Please list two non-family member references below: (Please list complete address)

Name

Mailing Address

State

Zip

Phone #

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

I understand that:

* The information that I have provided may be verified by a background check, a motor vehicle record check, sex offender registry, child abuse/neglect

registry, or any other means deemed appropriate, and I give permission to Special Olympics Connecticut, Inc. or Special Olympics, Inc. to make inquiry of others

concerning my suitability to act as a Special Olympics Connecticut, Inc. or Special Olympics, Inc. volunteer.

* The relationship between Special Olympics Connecticut, Inc. or Special Olympics, Inc. and volunteers is an “at will” arrangement, and this application may be

denied or the relationship may be terminated for any reason.

* In the course of volunteering for Special Olympics Connecticut, Inc. or Special Olympics, Inc., I may be dealing with confidential information and I agree to

keep said information in the strictest confidence.

* I grant Special Olympics Connecticut, Inc. or Special Olympics, Inc. permission to use my likeness, voice, and words in television, radio, or in any form to

promote activities of Special Olympics Connecticut.

* I affirm that I have read the above and that the information I have given is true and complete.

SIGNATURE: ______________________________________________________ DATE__________________________________