Hartford Gay & Lesbian Health Collective
Online Volunteer Application

Basic Information

Today's Date:
Name:
Home Address:
City:
State:       Zip: 
Home Phone:
Employer:
Work Address:
City:
State:       Zip: 
Work Phone:
Other Phone:
Email:

Experience

Work Experience (List Title, Employer, Date):

Volunteer Experience (Title, Employer, Date):

Availability
 

Day(s) and Time(s) Available:

Interests
 

In which areas are you interested in volunteering?

Skills & Qualifications

Summarize skills and qualifications you have acquired from employment, previous vollunteer work, or other activities:


 
Do you have a professional license(s) or certification(s) you wish to use? Yes    No
   
If Yes, please list your Connecticut License/Certification Number:
   
Have you ever been convicted of a misdemeanor involving a motor vehicle or criminal felony? Yes    No

Emergency Contact

Name:
Address:
City:
State:       Zip: 
Home Phone:
Work Phone:
Email:

References

Please list 2 personal references (other than relatives) that we may contact.

Reference #1:
 
Name:
Phone:
Address:
City:
State:       Zip: 
Relationship:

Reference #2:
 
Name:
Phone:
Address:
City:
State:       Zip: 
Relationship:

Statement of Understanding

If I am accepted as a volunteer, I agree to fulfill my volunteer obligations as outlined in these statements, the volunteer job description(s), the Volunteer Handbook, as well as through Volunteer Orientation, specialized training and periodic performance reviews. 

I am also aware that my actions and behaviors are a reflection of the agency and that, while serving in the capacity as a volunteer, I will represent the agency in a positive manner. I understand that if I engage in social or other activities with a client or group member that is beyond the scope of responsibilities of my volunteer position, then I do so at my own risk.

I also understand that any work I do on behalf of HGLHC as it relates to software applications, computer use, modification of any and all software applications or hardware is the sole property of HGLHC and will not be shared with or given to any other entity without the express written permission of the executive director of HGLHC.

I also understand that the Executive Director of the Hartford Gay and Lesbian Health Collective, Inc., has the right, at any time, for any reason, to request that I provide (at my own expense) a local, state and/or federal criminal background check, including sexual offenses, a Department of Motor Vehicles driving record, an updated insurance and/or licensure certificate, and two forms of visual identification.

 Confidentiality Statement

As a volunteer for the Hartford Gay and Lesbian Health Collective, Inc., I understand that during the course of my work I may learn information about clients, group participants, staff, board of director members and/or other volunteers or individuals involved with this agency, that is highly personal and confidential. Such information may include name, financial information, medical treatment and condition, living arrangements, employment, gender identity, sexual orientation, personal relationships, etc. I understand that all such information must be treated as completely confidential. I agree not to disclose this information without the express written consent of the individual or the formal approval of the Executive Director. I understand that violation of this agreement may result in adverse effects for the individual and may affect the continuation of my volunteer service with the HGLHC, Inc.

Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I agree to the terms outlined in the Statement of Understanding and the Confidentiality Statement.

Please check here if you are volunteering to fulfill a school, civic, community, or legal requirement that requires HGLHC to provide written documentation to a third party of your volunteer service. It is important that we have a discussion about this requirement prior to you beginning your volunteer work at HGLHC to assure we are able to provide you with the documentation you require.

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Hartford Gay & Lesbian Health Collective
P.O. Box 2094, Hartford, CT 06145
Tel: (860) 278-4163