Volunteer Program Application

Thank you for your interest in volunteering at DakotAbilities.

Employer Name

Have you read and do you accept and understand the above statement?

Yes

No

PLEASE READ THE FOLLOWING

I understand that:

- The information I have provided may be verified and I give permission to DakotAbilities to make inquiry of others concerning my suitability to act as a DakotAbilities volunteer.

- In the course of volunteering for DakotAbilities, I may be dealing with confidential information and I agree to keep said information in the strictest confidence;

- The relationship between DakotAbilities and volunteers is an ?at will? arrangement and that it may be terminated at any time without cause by

Have you ever been convicted of abuse, neglect or assault?

Yes

No

Have you ever been convicted of a criminal offense?

Yes

No

Do you use illegal Drugs?

Yes

No

References - Please list three non-family references (Name, Relationship, Phone Number, Address)

Employer Address

Job Title

First Name

Email

Contact Number

Zip Code

State

City

Address

Middle Initial

Last Name

Please Enter The Number Below *

For questions contact the Volunteer Coordinator at 605-334-4220