ROSMY - Volunteer Form

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. Wouldn't you know it? We start advertising on the radio and suddenly our website forms die. Call us instead - 644-4800. Or e-mail: rosmy@rosmy.org
General Information
Name:
Address:
City:
State:		Zip:
Home Phone:
Work Phone:		Cell:
E-mail:
Date of Birth:	Mo. Day Year
Occupation:
Employer:

This following information is optional, and is used for grants and statistical purposes only:
Gender:
Race:
Sexual Orientation:

Education:
Education completed:
Did not finish high school
High school or GED
Some college		School:
College degree		School:
		Year:	Degree:
Graduate work or degree		School:
		Year:	Degree:

Volunteer Interests:
	(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 for 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 first hear about ROSMY?
Why do you wish to volunteer with ROSMY? (Specifically list 3 goals that you wish to attain)		Goal 1.
		Goal 2.
		Goal 3.
Have you volunteered with other agencies?		Yes No
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?		Yes No
If YES, what was the offense and when did it occur?
Have you been charged or convicted of any offense involving minors?		Yes No
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:
Address:
City:
State:		Zip:
Home Phone:
Work Phone:		Cell:
E-mail:
Reference 2
Name:
Address:
City:
State:		Zip:
Home Phone:
Work Phone:		Cell:
E-mail:
Reference 3
Name:
Address:
City:
State:		Zip:
Home Phone:
Work Phone:		Cell:
E-mail:



	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: Greg Harman 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.

Wouldn't you know it? We start advertising on the radio and suddenly our website forms die. Call us instead - 644-4800.

Or e-mail:

rosmy@rosmy.org

General Information

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

Education:

Volunteer Interests:

(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: Greg Harman PO Box 5542 Richmond, VA 23220-0542

Thank you again for your interest in volunteering with ROSMY!

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

ROSMY
Attn: Greg Harman
PO Box 5542
Richmond, VA 23220-0542