Is this a workplace or personal email?
Personal   Workplace

If it's a workplace email, may we contact you at that address?
Yes   No

Education Information

What College/University program are you attending?:

What is the basis of your interest in Vanessa Behan Crisis Nursery?:

Are you eligible for a work study?: Yes   No

Have you been on a "Vanessa's Promise" nursery tour? Yes   No

Shifts & Days Available

Please indicate all shifts for which you would be available

Employment & Volunteer History

May we contact your present employer? Yes   No

Next Previous Employer and Volunteer History

Next Previous Employer and Volunteer History

Additional Information

List any experience not previously included and account for periods of unemployment, including military service:

What experience do you have working with children from birth through age six? Please be specific:

Please list any unique skills or talents you possess for working with young children:

What are your reasons for wanting to work with children?:

Professional References

Please list 3 people other than friends or relatives who you agree we can contact

Reference #1

Reference #2

Reference #3

Criminal Disposition

Answering "Yes" to the following questions will not necessarily be a bar from volunteering. However, failure to answer these questions truthfully will result in your rejection as a candidate for volunteering.

Do you have any pending criminal charges? Yes    No

Have you ever been convicted of a criminal offense, pleaded no contest to charges, or agreed to enter in a pre-trial diversion or similar program in lieu of a criminal prosecution for any crime other than a minor traffic violation? Yes    No

If yes to any of the above questions, explain in detail and include the date, court, location, sentencing and disposition of the case. Please include information on any pending charges.

Applicant Acknowledgement

A. I understand that Vanessa Behan Crisis Nursery is an Equal Opportunity Employer. Vanessa Behan Crisis Nursery recruits qualified volunteers without regard to race, religion, color, sex, sexual orientation, age, national origin, citizenship and veteran or disability status, or any factors prohibited by law and as such affirms in policy and practice to support an promote the concept of equal employment opportunity and affirmative action, in accordance with all applicable federal, state, and municipal laws.

B. I understand that Vanessa Behan Crisis Nursery is committed to providing disabled volunteers with reasonable accommodations necessary for the completion of the application process and for performance of their essential job duties. I understand that if I need an accommodation in the completion of the application process or in the performance of my essential job duties, I should request one from the employment interviewer or the Director of Vanessa Behan Crisis Nursery.

C. I hereby give Vanessa Behan Crisis Nursery permission to request the preparation of an investigative consumer report that may include information relating to my criminal record and my character in connection with my volunteer application. Should I become accepted as a volunteer by Vanessa Behan Crisis Nursery, I hereby give Vanessa Behan Crisis Nursery permission to request the preparation of such an investigative consumer report at any time during my volunteer tenure. I understand that I have the right to request that Vanessa Behan Crisis Nursery completely and accurately disclose the nature, scope and results of the investigation requested. Such request must be in writing to the Director of Vanessa Behan Crisis Nursery for which I am a candidate. In addition, I also give Vanessa Behan Crisis Nursery permission to investigate my employment history and police record.

D. In accordance with applicable law, I agree to undergo a screening for illegal drugs in accordance with Vanessa Behan Crisis Nursery's Substance Abuse Policy, if otherwise requested, or as legally required. I understand that a positive test result for illegal drugs or controlled substances will render me ineligible for volunteer work, employment or internship with Vanessa Behan Crisis Nursery at the time of the positive test result.

E. I authorize Vanessa Behan Crisis Nursery to contact my current and former schools, references, and previous employers to verify the information I have provided in the application and interview process as well as information as to my performance, attendance record, and separation reason and I hereby release Vanessa Behan Crisis Nursery, its officers, directors, employees, insurers, agents, representatives and any such individuals, corporations, or organizations who provide such information from any liability or claims for damages in relation to such contacts.

F. I hereby certify and affirm that all information I have provided as part of this application process, including statements on this application and those made during the interview process are true and correct. I understand that providing any misrepresentation, misinformation, making any omission or otherwise causing any inaccurate to become part of my application record will prohibit my being hired as a volunteer and will result in my immediate termination if discovered after I am hired as a volunteer.

Please type your name below to acknowledge that you agree