*(denotes required field)

First Name: *

Middle Name:

Last Name: *

E-Mail Address: *

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BASIC INFO

Address *

City *

State *

ZIP *

Primary Phone *

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EMPLOYMENT INFO

Place of Employment

Position Title

Supervisor Name

May We Contact?

YES
NO

Supervisor Phone

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VOLUNTEERING INFO

How did you become interested in volunteering with AVOL?: *

I am applying to be a Volunteer due to a program requirement.

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SCHEDULE

Please indicate your weekly availability: *

Mon Day
Mon Eve
Tue Day
Tue Eve
Wed Day
Wed Eve
Thu Day
Thu Eve
Fri Day
Fri Eve
Sat Day
Sat Eve
Sun Day
Sun Eve

How many total hours are you willing to volunteer each month?

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HIV/AIDS-RELATED INFO

Do you know your HIV status? *

YES
NO

Which of the following best describes your knowledge of HIV/AIDS? *

Advanced
Intermediate
Basic
None

HIV/AIDS affects people of all backgrounds. Please indicate below if there are any groups of people with whom you would have difficulty working:

People:

with a different sexual orientation
of a different race
who have different religious beliefs
with mental disabilities
who are transgendered
of the opposite gender
under 18 years old
with physical disabilities
who actively use drugs or alcohol
who are elderly

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SKILLS AND INTERESTS

What experiences, skills, special education or interests do you bring to AVOL?

Check all that apply:

State HIV Testing and Counseling Certification
IT/Computer Skills
Communication Skills
Social Networking
Art/Photography
Office Skills
Social Work Skills
Other Special Skills

Please explain:

AVOL has a variety of volunteer opportunities. Please check all areas that interest you: *

Prevention and Outreach
HIV Testing
Client Services
Special Events
Administrative
Professional Services

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EDUCATIONAL INFORMATION

Education (highest grade completed): *

Are you currently a student?: *

YES
NO

If so, where?

Have you completed or are you currently enrolled in the United Way Get on Board Program?:

YES
NO

Languages Spoken Fluently: *

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OPTIONAL INFORMATION

Race/Ethnicity

Sex

Sexual Orientation

Religion

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TRANSPORTATION

Do you have a valid driver's license?: *

YES
NO

Do you have reliable transportation?: *

YES
NO

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BACKGROUND INFORMATION

Have you ever been convicted\imprisoned\ or fined for a felony?: *

YES
NO

If so, please explain:

Have you or a family member ever received services as a client of AVOL?:

YES
NO

Please list three references (other than relatives or AVOL Inc. staff) that we may contact. One reference must be a professional reference (I.e. present/previous supervisor, professor, etc.). Please give complete address:

Reference 1 Name: *

Reference 1 Address: *

Reference 1 Phone: *

Reference 1 E-mail:

Relationship to Reference 1: *

Reference 2 Name: *

Reference 2 Address: *

Reference 2 Phone: *

Reference 2 E-mail:

Relationship to Reference 2: *

Reference 3 Name: *

Reference 3 Address: *

Reference 3 Phone: *

Reference 3 E-mail:

Relationship to Reference 3: *

I hereby give AVOL (AIDS Volunteers, Inc.) permission to perform a check of my background, including criminal record, personal/professional references, and other persons or sources as appropriate for the volunteer positions in which I have expressed an interest.

I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for some types of volunteer activities.

I understand that information collected during this background check will be limited to that appropriate to determining my suitability for particular types of volunteer activities and that all such information collected during the check will be kept confidential.

I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability of the described volunteer activities and such other information, as they deem appropriate.

Type Name:

Check to sign:

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Background Check Data

Aliases/Maiden:

Date of Birth:

Address of Record:

Length of residency in Kentucky:

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CERTIFICATION

Type Name: *

I certify that all answers to the questions in this application are true and I further understand that any false statement in this application will be sufficient grounds of rejection of the application or termination of volunteer status without notice at any time hereafter. I agree to and authorize AVOL (AIDS Volunteers,Inc.) to complete a pre-employment drug screening and understand that a positive drug screening may result in rejection of the application. I further authorize AVOL to complete a criminal records check and a credit check if I have applied to a position subject to this requirement. I understand that the findings of a record check may be grounds for rejection of application or termination of volunteer status without notice. I authorize AVOL to make all necessary investigations to verify information contained herein, and authorize and release from liability any and all references to provide information relevant to my application for volunteering with AVOL.

Check to sign: *

CAPTCHA Code: *