Is there a specific skill, service or interest area you would like to offer?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Please check the following areas of service for which we can contact you for assistance:
 

Have you ever been a resident of any Merced County Rescue Mission program, or do you know any former or current resident?  Y____    N____
 

If yes, when and whom?

_______________________________________________________________

Do you have any specific health problems we should know about?

__________________________

Who should we contact in case of an emergency?
 

 

Other Skills:

______________________________________________________________________ ______________________________________________________________________

Other:  Interested in organizing a drive, please check here:   ______

If you are a Doctor (Medical, Dental, Optical, or Chiropractic) or a Lawyer, and are interested in volunteering in your specialty, please check here:  ______

PLEASE READ THE FOLLOWING STATEMENT AND SIGN BELOW:

I understand that as a volunteer at the Merced County Rescue Mission, I am not paid for my services and I will discharge my volunteer assignment with responsibility.  I will respect any resident's/client's confidential information which I may have access to.  I respect the privacy and anonymity of the residents and clients of the Merced County Rescue Mission.  I agree not to use such information without a prior Release Form signed by the resident.

______________________________________________________ Signature

_____________________________ Date

I hereby allow the Merced Country Rescue Mission to perform a check on my background as appropriate for the volunteer positions in which I expressed an interest, including:
 

	Criminal Record
	Driving Record
	Employment History
	Personal References
	Volunteer Experience

I understand that I do not have to agree to this background check, but that refusal may exclude me from consideration as an Merced County Rescue Mission volunteer.

This information is of a confidential nature, and as such will not be shared with other personnel except for those involved in this specific volunteer position.  All information collected will be kept confidential.

 

_______________________________________________________ Signature

____________________________ Date

_______________________________________________________ Volunteer Coordinator

____________________________ Date