Adult Education Program Volunteer Application Survey

1. Please enter today's date

	MM		DD		YYYY
Date	Please enter today's date Date Month	/	Day	/	Year

2. Please complete the following:

Please complete the following: Last Name:
First Name:
Date of Birth:
Age:
Gender:
Mailing Address Street:
City:
State (GA)
Zip
Cell Phone
Home Phone
Work Phone
email address:
Education Level Completed:

3. Strongest Subject Areas:

Strongest Subject Areas: Reading

Mathmatics

Language

Social Studies

Science

4. Availibility (Days of the Week):

Availibility (Days of the Week): Monday

Tuesday

Wednesday

Thursday

5. Availibility (Time of Day):

Availibility (Time of Day): Morning (9:00am to noon)

Afternoon (1:00 to 4:00pm)

Evening (5:00pm to 8:00pm)

6. Please list languages other than English:

Please list languages other than English: 1.
2.
3.

7. Please indicate civic affliations:

Please indicate civic affliations: Downtown Rotary	Uptown Rotary	Junior League	Optimist Club	Kiwanis Club	Other
Other (please specify)

8. Please describe previous volunteer experiences:

Please describe previous volunteer experiences:

9. Reference:

Reference: Name:
Relationship:
Phone:

10. Emergency Contact Information:

Emergency Contact Information: Name:
Relationship:
Address:
Phone 1:
Phone 2:

11. Have you ever been convicted, or ajudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than minor traffic violations?

Have you ever been convicted, or ajudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than minor traffic violations? Yes

12. Statement of Confidentiality - Volunteers, like instructors, are required to comply with policies that protect confidentiality and disclosure of student records and personal information that they become privy to as a result of working directly with the students. Disclosure of student records and personal information beyond program personnel and consultants having obligation of confidentiality, shall require written consent from the adult student.

I understand the above statement and will comply with the policy to maintain confidentiality and to respect the student's right to privacy, refraining from disclosure or confidential information and intrusion into the student's family life.

Statement of Confidentiality - Volunteers, like instructors, are required to comply with policies that protect confidentiality and disclosure of student records and personal information that they become privy to as a result of working directly with the students. Disclosure of student records and personal information beyond program personnel and consultants having obligation of confidentiality, shall require written consent from the adult student. I understand the above statement and will comply with the policy to maintain confidentiality and to respect the student's right to privacy, refraining from disclosure or confidential information and intrusion into the student's family life. Yes

13. Do you authorize the administration to use your picture in publications, brochures, flyers, displays and other promotional materials.

Do you authorize the administration to use your picture in publications, brochures, flyers, displays and other promotional materials. Yes

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Adult Education Program Volunteer Application

1. Volunteer Information