I. General Information * Required Information

* First Name:

* Last Name:

* Middle Initial:

* Address:

* City:

* State:

Zip:

* Home #:

*Cell #:

E-Mail:

* Date of Birth

* Driver License #:

* State issued:

* Social Security #:

* Employer:

Work #:

Occupation:

* Gender:

Race:

* Organization affiliation: i.e. church, school etc.

* Briefly please describe what you would like to help with at the Clubs and/or any special interest you have.
(i.e. church, school etc.)

II. Emergency Contact * Required Information

Name:

Relationship:

Address:

Home #:

Cell #:

Employer #:

Work #:

III. Availability * Required Information

Flexible

Prefer Days

Prefer Evenings

Monday

Tuesday

Wednesday

Thursday

Friday

Hours per day:
Hours per week:
Hours per month:

By signing and dating this form, I authorize the Boys & Girls Clubs of Fort Wayne, Inc. to conduct a background check in order to determine my eligibility as a future volunteer in one or all B&GCFW units. I have read, understood and completed this application and agree to hold harmless the Boys & Girls Clubs of Fort Wayne, Inc. , law enforcement agencies, and background search organization, in regard to use of information authorized for release and exchange. The Boys & Girls Clubs of Fort Wayne, Inc. reserves the right to reject this application without reason or for any reason whatsoever, without recourse against the Boys & Girls Clubs of Fort Wayne, Inc. or any of its employees, officers, directors, agents, affiliates, or other designees. Additionally, I hereby authorize the Boys & Girls Clubs of Fort Wayne, Inc. to independently verify my information as provided on this application.

I have read and agree.