ROSMY - Volunteer Form

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Thank you for your interest in volunteering with ROSMY. After completing this form, please follow the instructions below to complete a Criminal Background Check Request.

General Information:
First Name:
Last Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Home Phone:
Mobile Phone:
Email 1:
Email 2:
Date of Birth:	Mo. Day Year
Occupation:
Employer:

This following information is optional, and is used for grants and statistical purposes only:
Gender:
Race:
I Consider Myself:

Education:
(fill out all that apply)
Level:
School:
Degree:
Year:

My volunteer interests are:
(check all that apply)
Youth Services (training required and provided)
Administrative (office duties with various days and times available)
Technology Support (as-needed computer and technology help)
Special Events (helping to plan and staff special events)
Board Membership (set policies and direction of the agency)
Committee Membership (offering services in your area of interest or expertise)
I am interested in serving on the following committees:
(check all that apply)
Development and Fundraising
Public Education
Marketing
Outreach and Volunteer Training
Multi-Disciplinary

Background Information:
How did you hear about ROSMY?:
Why do you wish to volunteer with ROSMY? (list three goals) Goal 1:
Goal 2:
Goal 3:
Have you volunteered with other agencies?:
If yes, please list where and what role you served:
Please list any additional knowledge, skills or experiences you have to offer:
Have you ever been convicted of a criminal offense?:
If yes, what was the offense and when did it occur?:
Have you been charged or convicted of any offense involving minors?:
If yes, what was the offense and when did it occur?:

Please list three character references (please do NOT include family members):
Reference 1:
Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Reference 2:
Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Reference 3:
Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Mobile Phone:
Email:


After completing this form, please visit the Virginia State Police website and complete the Criminal Background Check form online. (Please note, the Virginia State Police website requires credit card information to access the form. You must enter the information but your card will not be charged.) On that form, please indicate the reply should be mailed to: ROSMY Attn: Shannon Reilly PO Box 5542 Richmond, VA 23220-0542 ROSMY will contact you to schedule an interview. A fee of $8.00 will be collected during the interview to cover the cost of the criminal background check.

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General Information:

This following information is optional, and is used for grants and statistical purposes only:

Education:

(fill out all that apply)

My volunteer interests are:

(check all that apply)

I am interested in serving on the following committees:

(check all that apply)

Background Information:

Please list three character references (please do NOT include family members):

Reference 1:

Reference 2:

Reference 3:

ROSMY Attn: Shannon Reilly PO Box 5542 Richmond, VA 23220-0542

Thank you again for your interest in volunteering with ROSMY!

Or donate now
through PayPal:

ROSMY
Attn: Shannon Reilly
PO Box 5542
Richmond, VA 23220-0542