Volunteer Form - Wedgwood

Personal Information

Name *

First

Middle

Last

Phone

Email *

Address *

Address Line 1

City

State

Zip Code

Volunteer Interests

(Select all that apply) *

Criminal History

Have you ever been convicted of a felony or misdemeanor in the State of Michigan and/or do you have pending felony charges against you? *

Yes
No

If you answered yes, please provide (a) the date of the conviction; (b) a description of the facts and circumstances relating to the conviction, including the County where you were convicted; and, if applicable, (c) a description of the pending felony charge, including the County where the charge is pending.

Are you listed as a perpetrator of child abuse or neglect on the Central Registry for Abuse and Neglect in the State of Michigan? *

Yes
No

Are you listed as a perpetrator of child abuse or neglect on the Central Registry for Abuse and Neglect in the State of Michigan?

Have you ever had a Child Protective Services’ investigation result in a confirmed case of child abuse or neglect against you regardless of whether you were listed on the Central Registry for Abuse and Neglect in the State of Michigan? *

Yes
No

If you answered yes, please provide (a) the date when the case of abuse or neglect was confirmed against you; and (b) a description of the facts and circumstances relating to the confirmation. (copy)

a Neglect as

Have you ever been convicted of a felony or identified as a perpetrator of child abuse or neglect in another state? *

Yes
No

If you answered yes, please provide (a) the date of the felony conviction and/or the date when you were identified as a perpetrator of child abuse or neglect; (b) the state where you were convicted or identified; and (c) a description of the facts and circumstances underlying your conviction or child abuse or neglect identification

Applicant Certification and Agreement

Carefully read the following statement and sign as specified below. I have completed this application, and hereby declare the information provided is true, complete and correct to the best of my knowledge. I understand that any misstatement or omission of fact on this application will be considered cause for my dismissal. I further authorize Wedgwood Christian Services to obtain references concerning my character, personal qualities, and past job performance. I understand that volunteers are accepted based on program need and best fit for residents’ treatment, and contingent on the status of my background check.

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Personal Information

Volunteer Interests

Criminal History

Applicant Certification and Agreement

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