Volunteer Online Interest Form

About You

Please fill out all information completely with up-to-date information.

Your Name*

First Last

Address*

Street Address Address Line 2 City State Zip Code

Do You Speak/Write Any Other Languages Besides English?

If so, please list the language and your level of competency with it.

Availability

Our facilities are staffed anywhere from 7am – 10pm, please list your daily availability.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Will You Submit to a Background Check?*

SafeNet employees and volunteers are all required to submit to have the following clearances (dated within the past 5 years): 1. PA Criminal History, 2. PA Child Abuse and 3. FBI Fingerprint.

Yes

No

Do You have any Current Clearances?

Current Clearances mean the date on the clearance must be within 5 years from today’s date and not expiring in the next 90 days.

Pennsylvania Criminal History Clearance (PATCH)

PA Child Abuse Clearance (CWIS)

FBI Fingerprint Criminal History Clearance (IDENTOGO)

Volunteer Interest

Which of the following opportunities interest you? (Select all that apply)

Opportunities at SafeNet*

# = requires more training

#Children’s Program

Clerical Assistant/Receiptionist

Community Events

#Community Outreach

#Counselor Assistant

Facility/Maintenance

#Legal/Court Advocate

Other Interests (please specify)

List special interests, hobbies and activities you enjoy, and civic or church groups you belong to.

Community Service Requirement?*

If this is a mandated community service requirement, please complete this section.

Yes

No

Required by?

Please select the reason you need this community service.

Contact Name

Person who is overseeing your requirement

Contact Phone Number

Contact E-Mail Address

Total Number of Hours Needed

Please enter a number from 1 to 80.

Needed by?

Your Preferred Means of Contact

Please select if you’d like us to reach out via e-mail or by phone.

Contact Me by:*

Your Email Address*

Please enter a valid e-mail address that you check often.

Your Phone*

Best Time to Call You*

Volunteer Online Interest Form