Volunteer Application Volunteer Application Thank You for your interest in volunteering with BCYMP. This application is for non-Mentor volunteer opportunities (ex. group/club volunteers, diversion program, youth volunteers, YAT volunteers, or office volunteers). Please email bcymp@bcymentoring or call 605-697-0444 if you have questions or would like assistance in filling out the form. About You Name * Local Address * Local Address Local Address Local Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Birth date: * Your Emergency Contact (Name and Phone Number): * Are there any special health care needs (physical, behavioral, emotional, dietary) we should be aware of? Additionally, please list any suggested accommodations we can make: * Phone Numbers Cell Phone * Carrier * Can we text you? Yes No Home Phone Work Phone Background Do you have a valid drivers license? * Yes No If so, Expiration Date of Driver's License Will transportation be a concern for you? (Select all that apply). I use BATA when available. I use LYFT when available. No, I own/have access to a vehicle and I am a licensed driver. No, I have arranged a trusted licensed driver to help me with transportation. I am unsure of transportation at the moment due to finances. I am unsure of transportation at the moment due to lack of transportation options. OtherOther Has an employer or other organization run a Background Check on you in the last six months? Yes (If available, please email the results as a attachment to bcymp@bcymentoring.org) No Have you ever been convicted or arrested for a Felony Offense? If yes, explain. * Yes No Please explain, * Have you ever been investigated in connection with a child abuse. molestation or neglect matter? If yes, explain. * Yes No Please explain, * Volunteering Questions How did you hear about bcymp? * Tell us about yourself! What skills, projects, interests do you have? Is there anything you don't/won't want to do? * Volunteer Type: * Individual Volunteer Group Advance/YAT Volunteer Are you a college student/organization? If so what is your Major or the club you are involved in? * How often would you like to volunteer? (ex.. One time/Number of Hours, Ongoing, etc.) * Are these required volunteer hours? If so, what is your deadline for when you need the hours by? * Would you be interested in making a donation to BCYMP to help us serve more kids? Yes, I am willing to make a one-time donation of $50. Yes, I am willing to make a one-time donation of $20. No, I'm sorry, but can't make a donation at this time. Consent to Participation (If volunteer is under 18, parenting adult need to sign). If volunteer is under 18 OR if Volunteer is not submitting themselves, this signature acknowledges Parenting Adult/Guardian and Volunteer are BOTH aware of/approves participation with BCYMP. Signing below allows for participation and also acknowledges the Volunteer is wanting and willing to be a BCYMP volunteer. This signiture line may only be skipped if the volunteer is over 18 and submitting self. signature keyboard Clear I certify that all the information above is correct. * signature keyboard Clear By my signature below, I acknowledge that I am voluntarily assuming the risks involved in participating with/in Brookings County Youth Mentoring Program (BCYMP). * signature keyboard Clear By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hearby (1) waive any claim or cause of action against and release from liability the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, and agents for any liability for injuries to my person or property resulting from my participation in/with BCYMP. (2) Agree to indemnify and hold harmless the Brookings County Youth Mentoring Program (BCYMP), its officers, employees, Mentors, and agents fro any claims, causes of action, or liability to any other person arising from my participation with BCYMP; and (3) consent that I am personally liable for any, or all, lost or damaged personal items/equipment. * signature keyboard Clear Submit If you are human, leave this field blank.
