SC Adult Community Volunteer Application

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Last Name *

Middle Name

First Name *

Check all the counties you wish to serve in. *

Avery

Madison

Mitchell

Watauga

Yancey

Required

Date of Birth

YYYY

Current Address *

How long have you lived at the above address? *

List previous address if you have lived at the current address less than two (2) years.

Phone Number *

Email Address *

Role in the Community (i.e. occupation, vocation, other volunteerism, etc.) *

Emergency Contact (Name, Phone#, Email) *

Availability (check all that applies) *

Days

Evenings

Weekends

Other:

Required

Is this Volunteer Work a requirement for another program? (schools, community service, etc) *

Yes

If you answered yes above, how many hours are required and what organization is this for?

Please check any of the upcoming Volunteer Training Sessions you are available for.

Option 1

What experience, if any, do you have working with this age range (11-17 years)?

Reference #1 (Name, Phone#, Email, Relationship) *

Reference #2 (Name, Phone#, Email, Relationship) *

Reference #3 (Name, Phone#, Email, Relationship) *

Have you ever been impacted by crime or delinquent behavior? If yes, please explain. *

Have you ever been convicted of a misdemeanor or felony? *

Yes

If yes, briefly explain including offense and conviction dates.

I authorize the Mediation and Restorative Justice Center to conduct a background check as is determined necessary for the Sentencing Circles for which I am volunteering. *

Yes

Please add your name and the date here to serve as your signature. *

Submit

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