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Volunteer Application for Boys & Girls Clubs of Kennebec Valley

Volunteer Opportunities

If you are interested in volunteering at any of our locations please complete the volunteer application along with a background check form and return it to the Sandra M. Prescott Clubhouse. If you have any questions please contact us at the numbers below.

They will only be accepted in person and not by fax, mail, or email.

First Name

Middle Initial

Last Name

Age

Date of Birth

Gender

Male

Female

Emergency Contact

Phone

Legal Address

City

State

Zip

Home Phone

Cell

Email Type

Email *

RACE-NATIONALITY (OPTIONAL):

SCHOOL INFORMATION (If applicable)

Name of School

Grade

REFERENCES

This is someone who is not a family member and over the age of 18

Reference #1

Reference #1 Phone

Reference #1 Cell

Reference #2

Reference #2 Phone

Reference #2 Cell

Reference #3

Reference #3 Phone

Reference #3 Cell

MEDICAL INFORMATION

Doctor’s Name

Doctor's Phone

Permission for Doctors/Hospital

Yes

No

Any Medical problems and/or allergies

Please Indicate any medications presently taking

Dentist’s Name

Dentist Phone

Are you a US Citizen to a legal resident of the US?

Yes

No

Do you have a valid driver license?

Yes

No

If, yes please indicate license number

State

Have you ever been convicted of any motor vehicle violations in the past 5 years? *

Yes

No

Have you been convicted of, pled guilty to, and/or pled nolo contendre to a crime? *

Yes

No

If yes, please explain

Are you here for a court appointed community service? *

Yes

No

If yes, how many hours and when must you completed by:

PREVIOUS COACHING / VOLUNTEER EXPERIENCE/ WORK EXPERIENCE

List three coaching or volunteering experiences you have had with children under the age of 18

1

2

3

Other community activities:

Program Interest or Sport you wish to coach:

Special Skills/Trades/Education:

When would you be available to volunteer?

Physical or mental limitations:

Volunteering in the State of Maine is considered an at-will opportunity. By signing this application I attest to the fact that the information provided is true, correct and complete. Any misstatement, omission of fact or misrepresentation on this application may result in dismissal. I authorize the Boys & Girls Clubs of Kennebec Valley to conduct a background check on me through the State Police, National Agency Check, Department of Human Services and the Department of Motor Vehicles to verify the information provided if over the age of 18.

Sign

Date

BGCKV Sandra M. Prescott Clubhouse

14 Pray Street, Gardiner Maine 04345

Phone 207-582-8458 | Fax 207-582-7902

BGCKV Chelsea Clubhouse

566 Togus Road, Chelsea Maine 04330

Phone 207-215-4193

BGCKV Palermo Clubhouse

501 ME-3, Palermo Maine 04354

Phone 207-592-1233

2018 Copyright Boys & Girls Clubs of Kennebec Valley

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