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Volunteer and Placement Student Application Form
Youth Diversion Program
299 Concession St., Kingston ON K7K 2B9
(Confidential when completed)
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VOLUNTEER INFORMATION
1- First Name *
2- Last Name *
3- Preferred Name
4- Pronouns
5- Gender
6- Birth Date *
MM
/
DD
/
YYYY
7- Address *
8- City  *
9- Province *
10- Postal Code *
11- Preferred Email *
12 - Preferred Cell Phone *
13- Present Occupation/Schooling *
14- Name of the Employment/School *
15- Length of present Employment/School
16- The highest level of education completed *
If you answered "other" in question 16, please elaborate. 
17- Experience with children/adolescents *
18- Other relevant experiences
19- How did you learn about Youth Diversion?
20- What brought you to volunteer at Youth Diversion?
21- Languages you speak/write other than English (list all languages)
22- Organizations you are/were affiliated with (list all)
23- What activities do you presently enjoy? (Select all that apply) *
Required
24- If you answered "other" in question 23, please elaborate. 
25- Are there any activities you haven’t tried yet but would like to? (Please list)
26- Do you have access to a reliable vehicle? *
27- Do you plan to use a vehicle for your volunteer activities? *

28- Skip this question if you don’t have a vehicle or do not intend to use your vehicle.

Do you have a valid driver’s licence?

Clear selection

29- Skip this question if you don’t have a vehicle or do not intend to use your vehicle.

Do you currently have insurance on your vehicle with $2,000,000 liablity


Clear selection

30- If you plan to use your vehicle during your participation in the program, is there any reason you feel that you should not be driving (medical, license restrictions, poor driving condition and/or night time driving...)


Clear selection
Due to our awareness of child safety issues, and our commitment to protecting youth, we are required to ask you information about your personal life. Answering YES to these questions may not necessarily exclude your participation in the Program.
31- Do you have any history of sexual involvement with a minor under the age of 18 while you were over the age of 18? *
If yes, please explain:
32- Do you now have any sexual inclination toward children under the age of 18? *
If yes, please explain:
33- Have you had any negative police contact, including being investigated by the police, charged etc? *
If yes, please explain:
34- Is there anything else you would like us to know? (Please share any additional information)
35- Please select all the times you are generally available.   *
Required
36- Do you have preferred  dates and times you'd like to volunteer, please indicate below. 

37- Please list three references. 

References must be someone who has known you for at least two years. References must not be directly related to the applicant. It is better to name someone who has known you on a personal level. These references will be contacted either in writing or by phone. Please let them know that you have given us their name.

I hereby authorize the Youth Diversion Program to contact my references and seek other information to determine my suitability as a volunteer. I certify that the information given in this application is true, correct, and complete to the best of my knowledge and belief, and that any false impressions I may relay in my application or interviews could prevent me from volunteering with the Program. I also understand that from time to time during my active volunteering, the Youth Diversion Program may conduct subsequent police and reference checks. In order to ensure all information is current.


For each reference, follow this order: Name / Relationship / City / Phone number / Date 

38- Please insert date and type initials
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