M-A-D Prison Ministry Volunteer Consent

(Make a copy, complete it & email: andthetruthshallmakeyoufreeyes@gmail.com or bring it to us ok?)

Name:________________________________________________________________________________________

Phone Number:______________________________________ Date of Birth:______________________________

Home Adress:___________________________________________________________________________________

City:____________________________________ State:_________________________ Zip:_________________

Employed By? (if employed): _____________________________________________________________________

Phone Number:__________________________

Address:_______________________________________________________________________________________

City:____________________________________________ State:________________________________

Zip:__________________________________________

May we call you at work? _________yes ________no

Brief discription of work?__________________________________________________________________________

_____________________________________________________________________________________________

______________________________________________________________________________________________

Highest year of school completed?___________________________________________________________________

Do you speak any foreign language? ___________________yes ______________________no

If yes which language?____________________________________________________________________________

Do you drive? _____yes _______no

Do you have regular access to a car? __________yes ____________no

Current community activities?

______________________________________________________________________________________________

List of current and previous volunteer work (list all previous volunteer work including brief desription of duties and activities)

______________________________________________________________________________________________

What are your reasons for wanting to participate as a VCCEADCS volunteer?

______________________________________________________________________________________________

Have you had any personal experience(s) involving: Rape, Abortion (pro-life), Incest, Molestation, Human Trafficking, Orphans, Sex Trafficking if yes explain:

______________________________________________________________________________________________

How did you learn about our program?

______________________________________________________________________________________________

Have you ever been convicted of a crime other than a traffic violation? __________yes ____________no

If yes what charge(s)?____________________________________________________________________________

______________________________________________________________________________________________

Date(s) convicted?________________________________________________________________________________

______________________________________________________________________________________________

Where?________________________________________________________________________________________

______________________________________________________________________________________________

Do you consent to a routine check of your criminal records? __________yes _________________no

Please list 3 references of people who know you well, other than relatives, preferably for whom you have worked for in either a paid or volunteer capacity. If you are working either paid or volunteer please include the name of your supervisor.

Name Address Zip Code Phone Relationship

______________________________________________________________________________________________

How long have you lived in the area?________________________________________________________________

When can you begin volunteering?_____________________________________________________________________

VCCEADCS reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All info obtained will be held in the strictest confidence.

___________________________________________ ______________________________________________

Sign Date