Volunteer Application

Thank you for your interest in volunteering at GoochlandCares! We rely on volunteers to staff our 12 programs to help our Goochland neighbors in need. Please tell us about yourself, so we can match your interest, skills, and availability to our program needs.

First Name *

Middle Name

Last Name *

Email Address *

Primary Phone Number *

Alternate Phone Number

Address *

Address

City

State

ZIP

Date of Birth *

Gender *

Female

Male

Clinic volunteers and volunteers who provide direct client service must be 18 years old and no longer in high school.

Employer and/or School

When are you available to volunteer?

Start Date *

Day(s) Available *

Check all that apply.

Saturday morning = Clothes Closet only

What program(s) would you like to volunteer in?

Program(s) *

Food Pantry

Clothes Closet

Dental Clinic

Medical Clinic

Home Repair

Domestic/Sexual Violence

Administrative

Tax Preparer/Financial Counselor

OtherOther

Check all that apply.

Clinic Volunteers *

Dental Assistant

Dental Hygienist

Dentist

Medical Assistant

Registered Nurse

Nurse Practitioner

Physician

Physical Therapist

Podiatrist

Licensed Social Worker

Licensed Mental Health Provider

Professional License # *

What type of skills and experience do you have?

Please include any skills or certifications (i.e. Spanish interpreter, CDL, CPR, electrician, contractor, etc.) you have and describe your volunteer experience.

Special Skills or Certifications

Volunteer Experience

Are you required to complete community service for school, court, a club, or any other reason?

Community Service *

No

Yes

Reason *

school required

court-mandated

employer required

OtherOther

Explanation *

Please explain why school (i.e. National Honor Society), court (i.e. speeding ticket) or employer (i.e. matching hours) is requiring hours.

Number of Hours *

How many hours are you required to complete?

Date Due *

When are the hours due?

Are you a college student or intern?

College Student or Intern *

No

Yes

School or Program *

What school are you attending? If you are in a special program (i.e. Partnership for the Future), what is the name of the program?

Hours *

How many hours are required?

How did you hear about GoochlandCares?

Why do you want to volunteer at GoochlandCares?

Who should we contact in case of an emergency?

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Email

Volunteer Agreement

By submitting this volunteer application, I agree to adhere to the following policies. 1) Confidentiality Agreement: ACCESS TO and PROTECTION of CONFIDENTIAL INFORMATION During my work, I will have access to certain personal and valuable information about our clients, volunteers, donors, staff, and organization. Such information includes, but is not limited to, personal information, situations, medical and social history, employment, finances, and other personal information. (Such information collectively is the “Confidential Information.”) I acknowledge and agree that all the Confidential Information is to be kept strictly confidential. No reference shall be made inside or outside the organization about a client’s identity, situation, treatment or other confidential information. Donor, volunteer, and staff personal and employment information is also to be kept confidential. This includes verifying if a person received our services and giving information to the parent of a child 18 years or older. 2) Volunteer Policies: I agree to volunteer policies outlined in the Volunteer Handbook, which is available by clicking below. I represent that I am competent to contract and have read and fully understand the contents, impact and meaning of these policies. 3) I agree to adhere to the GoochlandCares Covid-19 Policies and Procedures, which are available by clicking below.

Volunteer Handbook

Covid-19 Policies and Procedures

Volunteer Agreement *

I agree

Publicity Release

Do you give permission to GoochlandCares and its licensees and assigns to photograph me, and to publish, transmit and share in any form of media my photographs and any information based on interviews that I have given?

Publicity Release *

Yes

No

GoochlandCares provides equal opportunities without regard to race, color, gender, national origin, religion, sexual preference, age or disability.

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