Prevent Child Abuse Rockdale

www.pcarockdale.org

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Latest News

• Purchase a succulent smoked turkey for your family for Christmas dinner AND help prevent child abuse in your community at the same time! •

• PCA Rockdale Newsletter 2011 •

• We were in the news! Click for more info! •

• FREE Parenting Classes!
Tuesdays, Jan 24tth - Mar 6th 2012 •

• NOW serving Newton County with our in-home parenting program. The Newton Positive Parenting Program serves parents and parents-to-be who are ages 12 to 25. •

Mission Statement: PCA Rockdale exists to prevent child abuse in Rockdale County through awareness, education and collaboration.

Core Values:

Prevention of all forms of child abuse
Healthy/nurturing environments for children
Child-friendly collaborations
Resourced child care providers

Volunteer Application

Please fill out this application as completely as possible. As you know, our volunteers may be involved in programs that provide direct services to children. For that reason, please understand that we must screen all of our volunteers thoroughly. Your information will remain confidential and we do not ever share or sell our data.

* Fields in bold are required.
Click here if you would like a printable PDF form.

First Name

Middle

Last Name

Address

City

State

Zipcode

Home Phone	Work Phone	Mobile Phone
Email Address

Best Time to be Contacted

Date of Birth

Best Day(s) to volunteer

Mon Tues Wed Thurs Fri
Sat Sun

Number of hours available per week

Have you ever been a program participant? Yes No

If “Yes”, which one and when?

Volunteer positions held in the past

Where are you employed?
Fulltime Partime

What skills/talents do you have which might be useful in this program?

What training/experiences do you have which might be useful in this program?

Have you been convicted of a criminal offense? Yes No

If “Yes”, please explain below?

If you have you been convicted of or been involved in any activities related to child abuse, please explain below.

References:
(Please provide name & phone of three references, including a former supervisor)

Name:	Number:
Name:	Number:
Name:	Number:

I certify that all information provided in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration, and may result in my removal if discovered at a later date. I understand that approval of my application is contingent upon the results of a reference and background review, and I hereby authorize PCAR and its agents to investigate the truthfulness of all information I have provided on my application, resume, and other attachments. I give consent for all contacted persons to provide information concerning my application, and I release each such person from liability for providing information to PCAR and its agents. I hereby request and agree that PCAR will respond to inquiries made as a part of a reference check by prospective employers. I agree to waive any right to bring legal action against PCAR and its agents for the disclosure of such information.

Signature

Date