Compeer Program Volunteer Application

47 Broad Avenue Binghamton, NY 13904
Phone (607) 771-8888
Fax (607) 771-8892

Mental Health Association of the Southern Tier ● 47 Broad Avenue ● Binghamton ● New York ● 13904 ● (607) 771-8888

COMPEER Mentoring Program - Volunteer Application

Compeer Youth Mentoring Program
Phone: (607) 771-8888 ext. 315
E-mail: erin.sweeney@MHAST.org

The Compeer Youth Program encourages at risk youth to build self confidence, self-reliance, and healthy relationships by involving them in one-to-one mentorships, innovative programs, and regular positive social contact. The answers to the following questions help the Compeer staff to match you with an appropriate person who will benefit from your friendship. Compeer does not discriminate based on race, creed, color, religion, gender, age, national origin, marital or veteran status or sexual orientation. Compeer is aware of the sensitive nature of some of the questions asked on the application form and during the interview process. It has been our experience that having as much information as possible about each individual, whether a volunteer or client, increases our ability to match people successfully. All information is requested to ensure, to the greatest degree possible, the success of the matching process. If you have any questions about any part of this form or are uncomfortable answering any of the questions, please speak directly with a Compeer Volunteer Coordinator.

**NOTE: PLEASE REMEMBER TO BRING YOUR DRIVER’S LICENSE AND A COPY OF THE DECLARATIONS PAGE FROM YOUR AUTO INSURANCE POLICY* TO YOUR INTERVIEW**

*(Declaration of Auto Insurance required only by those 21 and older)

WE ARE REQUIRED TO SCREEN ALL OF OUR VOLUNTEERS

I am interested in Volunteering for the following

Compeer Adult Program

Compeer Youth Program

I’m interested in both Compeer Programs

Name:
(Last, First, Middle Initial)

Date of Application:

Email Address:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone and Extension:

Cell Phone:

How and when can we best reach you?

For Students:

Street Address (if different):

City:

State:

Zip Code:

Email Address When Not in School:

Phone When Not in School:

Place of Birth

City:

State:

Emergency Contact

Name:

Relationship to You:

Phone (Day):

Phone (Evening):

Cell Phone:

THE FOLLOWING ITEMS ARE FOR STATISTICAL PURPOSES AND TO HELP US MATCH YOU:

Date of Birth:

Gender:

Highest Level of Education Completed:

Race / Cultural Identity:

Employer:

Occupation / Title:

Previous volunteer experience:

What prompted your interest in volunteering?

Do you have access to transportation? Yes No

What Type? Car Bus Other

Do you have any special needs for transportation? Yes No

If yes, please explain (e.g., wheelchair access, etc.)

Do you have any medical / psychological conditions or physical limitations that would affect your ability to volunteer? Yes No

If yes, describe:

HOW DID YOU LEARN ABOUT COMPEER? CHECK ALL THAT APPLY:

Compeer Volunteer

Presentation – Where?

TV – Which Station?

Radio – Which Station?

Religious Community – Which?

Club / Civic Organization – Which?

Newspaper / Magazine – Which?

Poster / Flyer / Bookmark – Where?

Employer

School – Which?

Other

CRIMINAL HISTORY INFORMATION: I certify to the best of my knowledge and belief that I:

Have Have not been convicted of a crime in New York State or any other jurisdiction.

Do Do not have any pending felony or misdemeanor charges.

Note: If you have checked either “Have” and/or “Do” please provide a brief explanation.

REFERENCES

(Employer References)

We require a minimum of two references, which may be professional or personal, that can comment on your ability to serve as a volunteer. The reference cannot be a relative or reside in the same household and must have known you for at least one year.

Job 1

Employer:

From:

To:

Supervisor Name:

Area Code & Daytime Phone:

Email Address:

Street Address:

City:

State:

Zip Code:

Job 2

Employer:

From:

To:

Supervisor Name:

Area Code & Daytime Phone:

Email Address:

Street Address:

City:

State:

Zip Code:

(Personal References)

Reference #1:

Personal Reference Name:

Email Address:

Street Address:

City:

State:

Zip Code:

Area Code & Daytime Phone:

Length of Association:

Nature of Relationship:

Reference #2:

Personal Reference Name:

Email Address:

Street Address:

City:

State:

Zip Code:

Area Code & Daytime Phone:

Length of Association:

Nature of Relationship:

INTERESTS / HOBBIES / ACTIVITES

Arts:

Sports:

Movies:

Crafts:

Outdoor Activities:

Drama:

Sewing:

Gardening:

Games:

Reading:

Fitness Activities:

Music:

Animals:

Dancing:

Shopping:

Dining Out:

Volunteering:

Church / Temple:

Collecting (specify):

Cooking:

Other:

THE FOLLOWING ITEMS ARE FOR STATISTICAL PURPOSES AND TO HELP US MATCH YOU

Clubs / Civic Organizations:

Can you speak a foreign language? Yes No
If yes, please specify:

Sign Language? Yes No

Religion:

Congregational Affiliation:

Do you smoke? Yes No

Does it matter to you if client smokes? Yes No

Is it important that your friend be a specific age, gender, religion, and ethnic background or have a specific quality? Yes No
If yes, please specify:

Please add any comments or information that will help Compeer in finding an appropriate match:

When are you available to meet with your Compeer?

Daytime

Evenings

Weekdays

Saturdays

Sundays

Please read the following carefully and sign on the line provided:

I understand and fully acknowledge that, in volunteering for Compeer MHAST, Inc., I am entering an AT WILL relationship and that this relationship can be terminated at anytime by Compeer MHAST, Inc. or me.
I further understand by signing this agreement, I give permission to Compeer MHAST, Inc. to check driving and / or criminal background. I agree to a fingerprint check administered by the Greater Binghamton Health Center. I understand that all released information will be held in strict confidence and used only to assist Compeer MHAST, Inc. in making an appropriate match.
I understand by signing this application, I give permission to Compeer MHAST, Inc. to contact the references provided.
It is my understanding that all information I provide to Compeer MHAST, Inc. is true and complete to the best of my knowledge. I understand that giving false information may be sufficient cause for immediate dismissal.
I further understand that I will be asked to undergo training, where applicable, for Compeer MHAST, Inc.
I understand that, as a volunteer, I will help my Compeer friend to the best of my ability in accordance with the policies of the agency and will maintain complete confidentiality concerning all information on Compeer friends. I further understand that submission of a completed application, along with an interview by a Compeer staff person, does not obligate me to accept, nor Compeer to assign, a volunteer opportunity. I understand that, if I am to be matched, some of this information may be shared with the potential match and their therapist.

By the applicant entering their name in the box below, they are electronically signing this application and it carries the same legal value as if it were signed by the applicant in person.

Volunteer’s Signature:

Date of Application:

Thank you for taking the time to complete a Compeer Application!

If you have any questions regarding our Compeer Programs, this application or the application process please call our Volunteer Coordinator at (607) 771-8888 ext. 315