Urban League of Broward County

First Name

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Last Name

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Address

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City

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State

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Zip Code

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Phone #

Day Phone #

Cell Phone #

Employer

Employer Address

E-mail Address

Special professional training, skills, hobbies

Community affiliations (Clubs, Service Organizations, etc.)

Previous volunteer experience (including baseball/softball and year)

Special Certifications (i.e. CPR, Meditcal, etc)

Do you have a valid driver's license

*

Yes
No

Driver's License # and State

Have you ever been convicted of or plead guilty to any crime(s)

Yes
No

If yes to above, describe each in full

Ever been refused participation in any other youth programs?

Yes
No

If yes to above, please explain

Volunteer Preferences: Check all that apply

Tutoring

Mentoring

Writing

Office Skills

Techinical Skills

Marketing

Other Skills

Please list three references, at least one of which has knowledge of your participation as a volunteer in a youth program.

Names and Phone Numbers of References

Desired Position

Comments

Background Check Compliance
As a condition of volunteering, I give permission for the Urban League of Broward County to conduct a background check on me, which may include a review of sex offender registries, child abuse and criminal history records. I understand that, if appointed, my position is conditional upon the league receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the Urban League of Broward County, the officers, employees and volunteers thereof, or any other person or organization that may provide such information. I also understand that, regardless of previous appointments, The Urban League of Broward County is not obligated to appoint me to a volunteer position. If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the President and CEO and removal by the Board of Directors for violation of the Urban League of Broward County policies or principles.

I give permission to conduct a background check as stated above.

Media Release
I hereby give Urban League of Broward County, their assigns, licensees and legal representatives the irrevocable right to use my name, picture, photograph, portrait, visual likeness or voice in all forms and media in all manners, including photo, film, audio and video representations, for non-profit, public purposes and I hereby waive any right to inspect or approve the finished product that may be created in connection therewith.I have read this release and am fully familiar with its contents.

I comply with the above media statement

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