City Impact Volunteer Application

Name*
First Last
Gender
- Male
- Female
- Prefer not to say
Phone
Email*
Address
Street Address Address Line 2 City State ZIP Code
What areas are you interested in volunteering for?*
- CI Kids (Children's Bible Club)
- CI Youth (Teen Bible Club)
- CI Reading
Permanent Address
If you're a student please give us a permanent address

Street Address Address Line 2 City State ZIP Code
Employer Name
Marital Status
- Married
- Other
Emergency Contact Name
First Last
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Address
Street Address Address Line 2 City State ZIP Code

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How did you hear about City Impact?
Why do you wish to volunteer at City Impact?
Have you worked or volunteered with City Impact previously?
- Yes
- No
If so, in what capacity did you work/volunteer for City Impact?
Do you have a police record?
- Yes
- No
If yes, please explain.
Have you ever been accused, charged, or convicted of abuse (sexual abuse, child abuse, or other)?
- Yes
- No
If yes, please explain.
Have you ever been convicted of a felony or misdemeanor classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance?
- Yes
- No
If yes, please explain.
Do you have any special skills or talents that would contribute to your success in this role?
Do you speak any other languages? Please specify and provide level of fluency.

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Reference One
Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Number of Years Known*
Organization/Relationship*
Reference Two
Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Years Known*
Organization/Relationship*
Reference Three
Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Years Known*
Organization/Relationship*

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I give permission for City Impact to perform a check of my background including Social Security Number verification, Nationwide Criminal Record search, Statewide Criminal Record search, Nebraska Adult Abuse Registry search and Nebraska Child Abuse Registry search. I understand that I do not have to agree to this background check, but the refusal to do so may exclude me from consideration for some types of work. I understand that information collected during this background check will be limited to that appropriate to determining my suitability for particular types of work and that all such information collected during the check will be kept confidential.*
- Confirm
I understand that City Impact reserves the right to take my picture and use it for promotional purposes, unless check marked in the statement below.*
- Confirm
- I do NOT wish to have photographs I might be in published for the promotion of City Impact
Date
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Reference One