Application

THE BRIDGE

The domestic violence and sexual assault service provider for Dunn and Pepin Counties.

The Bridge To Hope Volunteer Application

Name: ________________________________________ Date ___________

Current Address: _______________________________________________

Home Phone: _________ Cell Phone: __________ E-Mail _______________

Date Of Birth: _________ Social Security #: __________

Emergency Contact:(Name & #) _____________________

Relationship To You: ___________

What Type of Volunteer Work?

Supportive Services (Intermittent and/or short-term)

	Clerical Work			Donation Pick-up/Delivery
	Transportation of client (on call)			Distributing PR/Educational Materials
	Grocery pick-up			Cleaning/Organizing
	Fundraising activities			Preparing welcome/exit kits
	Board Membership

Direct Services (6 Mo. Commitment or more & 40 hours of training)

	Legal advocacy			SA Advocacy
	On-call (1 wk/per month). Court watch/Research 1:1 Crisis Support			On-call (1 wk/per month) Attend SA nurse exams l: l Crisis Support/Court watch
	Co-Facilitate Support Group			Answering Crisis Hotline
	Child-Care			Relief Advocacy

Professional Services (Pro-bono)

	Legal Assistance			Electrical work
	Health/Nutrition Education			Carpentry
	Fitness/Relaxation Instructor			Painting
	Yard work			Roofing

What Hours Are You Available To Volunteer?

Monday			Friday
Tuesday			Saturday
Wednesday			Sunday
Thursday

1. How did you find out about The Bridge to Hope? (check all that apply)

___United Way ___Dunn County News ___Friend/Relative

___U.W. Stout ___Information Flyers ___Leader Telegram

___Other Newspapers ___Teacher ___T.V./Radio

___Current Volunteer ___Volunteer Placement Day

2. Please write a brief paragraph describing your understanding of domestic violence and sexual assault.

3. What are your reasons for volunteering for our agency?

4. What training, skills, or life experience do you have that you feel would be helpful to work at The Bridge to Hope?

5. The Bridge requires that all volunteers and staff sign a confidentiality agreement regarding the clients with whom we work. Also, the location of the shelter is to be held in the strictest confidence. Please discuss why you believe confidentiality is so important in the work that we do.

6. Have you ever been convicted of: (circle one)

Sexual assault yes no

Indecent exposure yes no

Lewd & lascivious behavior yes no

Any crime involving non-consensual sexual conduct/contact yes no

Child abuse yes no

Sexual exploitation of children yes no

Child abduction yes no

Child neglect yes no

Contributing to the delinquency of a child yes no

Enticing a child for immoral purposes yes no

Exposing a minor to pornography yes no

Exposing a minor to other harmful materials yes no

Any crime involving children as victims or participants yes no

Have you ever been arrested/convicted of assault/battery/disorderly conduct?

Yes No

7. If you answered yes to any of the categories, please explain:

Charge: _________________________________________

Conviction: ______________________________________

Against Whom: ___________________________________

What State: ______________________________________

Date: ___________________________________________

8. Please list three references: (no family members)

Name: ____________________________________

Address: __________________________________

Phone: ____________________________________

Relationship: _______________________________

Name: ____________________________________

Address: __________________________________

Phone: ____________________________________

Relationship: _______________________________

Name: ____________________________________

Address: __________________________________

Phone: ____________________________________

Relationship: _______________________________

No one deserves to be abused. 1-800-924-9918 We are here to help. Free & Confidential Services