St. Perpetua :.. Volunteer Application

CATHOLIC YOUTH ORGANIZATION
Diocese of Oakland
VOLUNTEER APPLICATION

PLEASE PRINT LEGIBLY OR TYPE. DO NOT LEAVE ANY BLANKS

Last Name:

First Name:

Middle Name:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Date of Birth (M/D/Yr.):

Social Security #:

Parish:

DRIVERS LICENSE INFORMATION-Because you may be driving minors to events, please provide the following information.

State:	License Number:	Class:	Expiration Date:
Insurance Carrier:	Policy Number:	Amt of Liability Coverage:	Amt of Medical Coverage:

NOTE: Diocesan insurance regulations require that drivers are over 21 years of age (preferably over 25); provide evidence of a valid, unrestricted drivers license; produce evidence of minimum liability insurance coverage of $1000,000 per person, $300,000 accident. All passengers must wear a seat belt and no more than nine persons may be transported in one vehicle.

EMPLOYMENT HISTORY - Begin with present or most recent position.

From:

Through:

Title:

Duties

Employer:

Address:

Phone:

From:

Through:

Title:

Duties

Employer:

Address:

Phone:

REFERENCES Please list two references who can attest to your work with young people. Exclude employers and relatives.

Name:

Address:

City, State, Zip

Phone Numbers:

Home:

Work:

Name:

Address:

City, State, Zip

Phone Numbers:

Home:

Work:

CONVICTIONS - Conviction of a crime is not necessarily a bar to volunteer employment. Each case is considered separately. Conviction of a sexual crime will bar you from volunteering in youth programs in the diocese.

1.  Have you ever been convicted by any court of a criminal offense? Yes No
     Omit:    a. Minor traffic violations;
                 b. Any offense committed prior to your 18th birthday which was finally adjudicated in a
                     juvenile court or under a youth offender law;
                 c. Any incident sealed under Welfare & Health Institutions Code #781 or
                      Penal Code #1203.45

2. If the answer to 1. is "Yes," state what offense, when, where, and disposition of case:
_________________________________________________________________________________
_________________________________________________________________________________

3. Have you ever abused or been convicted of having abused a child, sexually or otherwise Yes
Please explain. Include dates and disposition of legal proceedings against you. No
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

GENERAL INFORMATION
Have you coached CYO Sports before?_______ If yes, list sports, dates, grades and parishes:
____________________________________________________________________________________________

Have you coached other youth sports before?______ If yes, list sports, dates, grades or organizations:
____________________________________________________________________________________________

Have you worked with youth previously in programs other than sports?_______ if yes, list: _____________________
____________________________________________________________________________________________

Are you certified in Red Cross First Aid?___________ CPR?_______________

Have you ever been disciplined or removed by another parish program, or by any other youth-serving
organization?_______ If yes, please detail: ___________________________________________________________
____________________________________________________________________________________________

Please state why you wish to volunteer: _____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

CERTIFICATION AND SIGNATURE
I certify that the above answers are accurate and true to the best of my knowledge and belief. I authorize investigation of all statements contained in this application for volunteer employment as may be necessary in arriving at a volunteer employment decision.
I will agree to abide by all CYO rules and policies, the CYO Code of Conduct, and the directions of CYO officials. I understand that to volunteer, I must be accepted by the parish organization and complete Diocesan Coaches Certification requirements.

Date__________________________ Signature___________________________________________

PLEASE PRINT OUT THIS FORM;
WHEN COMPLETED (INCLUDING SIGNATURE), FAX TO (925) 299-2374