PAS Lynchburg – Volunteer Registration Form | Virginia Center for Inclusive Communities

Personal Information

LYNCHBURG PREJUDICE AWARENESS SUMMIT FACILITATOR APPLICATION

Please complete the application by December 16, 2022

Full Name (First, Middle, Last) *

Name I Prefer to be called *

Home Phone

Please include your area code

Cell Phone *

Please include your area code

Work Phone

Please include your area code

Email *

Street Address *

Country

City

State

Zip code

PAS Referral Organization

Click to select from the drop down options.

I prefer to be reached by *

Home Phone

Work Phone

Cell Phone

Email

Dietary Restrictions (please be specific): *

Demographic Information

Please provide the following demographic information. Be as specific as possible.

*This information will be used to ensure that we have as diverse a community at PAS as possible.*

Gender *

Pronouns

Date of Birth *

Religious Identity *

Is there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.)

Medical Information

Medical Emergency Contact *

Medical Emergency Contact Phone *

Do you have any medical considerations that may restrict participation in program activities? *

Yes

No

If yes, please explain

Application Questions

Please give the name, email address, and phone number of two references that you have known for at least three years who are not related to you. *

Why do you wish to be a part of the PAS experience? What do you expect to gain as a result of being a facilitator? *

What specific qualifications, strengths, or insights would you bring to the position for which you are applying? *

If selected for this program, I commit to being present at:
- - Facilitator Orientation – on Wednesday, January 4, 2023 (5:30pm - 8:30pm)
  - PAS– on Thursday, January 12, 2023 (7:45am - 2:45pm)

I understand that although the Virginia Center for Inclusive Communities (“sponsor”) has taken precautions to provide proper organization, supervision, and instruction for each activity, it is impossible for the sponsor to guarantee absolute safety. I also understand that each participant/volunteer shares the responsibility for safety during all activities and I assume that responsibility for myself. I waive any claim that may arise against the Board of Directors of the sponsor, and/or its employees, agents, volunteers, or lessors including those claims which may arise from the negligence of the sponsor, their Board of Directors; and/or its employees, agents, lessors or volunteers.

I understand that volunteer facilitators are asked to complete a series of written evaluations that assess their views on the PAS program after the program.

I understand that I, alone or with other participants and/or sponsor staff, volunteers, or representatives, may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) by the sponsor and/or others approved by sponsor.

I understand that volunteers must maintain appropriate conduct and follow clear guidelines with all minors participating in PAS. Appropriate conduct and guidelines are outlined on the “Facilitator Code of Ethics: Professional Boundaries When Working with Minors” sheet.

I certify that the information provided in this application is true and complete. I authorize the sponsor to investigate the facts presented in this application and to secure any necessary information from all employers, references, academic institutions, and other organizations. I also agree to execute any additional written authorizations necessary for sponsors to obtain access to and copies of records pertaining to this information. I agree to release any person, company, or other institution from any and all cause of action that otherwise might arise from supplying sponsors with information it may request pursuant to this release.

I understand that acceptance of my offer of volunteer services to the sponsor is contingent upon receipt of satisfactory responses to any or all investigations conducted by the sponsor. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application, or for my immediate discharge if discovered after I begin providing volunteer services. I agree to comply with all applicable policies, procedures and rules of the sponsor, and I understand that any violation may result in my immediate dismissal as a volunteer. I understand that nothing in this application, or in acceptance of my offer of volunteer services, is intended to create an employment contract between the sponsor and me.

Agreement

I hereby acknowledge that I have read and understand the preceding statement *

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Date *