Central Va. Disability Association, Inc.

Support - Advocacy - Faith - Empowerment

Volunteer Form for CVDA

Volunteer Application for

Central Virginia Disability Association, Inc.



Name: __________________________________________________ Date: ______________
(Last) (First) (Middle)

Address: __________________________ City: ___________ State: _____ Zip: __________

Mailing Address (if different): ____________________ City: _______ State: ____ Zip: _____

Home Phone: (_____)_________________ Work Phone: (_____)____________________

Cell (_____)__________________________ Fax: (___)___________________________

E-Mail: ________________________________ May we call you at work? Yes ____ No ____

Birth Date: _____/_____/_____ Are you over 18? Yes ____ No ____
(Mo.) (Day) (Year Optional)

Emergency Contact:

Name: _________________________________________ Phone (___)__________________

Relationship: _____________________________________

Medical information we should know in case of an emergency: ________________________


o How did you hear about CVDA?________________________________________________



o Why are you interested in volunteering with CVDA? _______________________________



o Have you previously volunteered here? Yes ____ No ____

If yes, in what position? __________________________________________________

I. Education/Employment/Volunteer Service Background

o Highest level of Education: _______________________ Major? ____________________

o Are you a current student? Yes ____ No ____ If yes, name of school: _______________
Grade ______ or Level______

Is volunteer experience required by your program? Yes ____ No ____
If yes, please explain: ________________________________________________

o Employer (Current): __________________________ Supervisor: _________________

Position held: ________________________________ Phone:(___)_________________

Address: ___________________________ City: __________State: ____ Zip: _______

Date employed: _________

o Employer (Previous): __________________________ Supervisor: _________________

Position held: _________________________________ Phone:(___)_______________

Address: ___________________________ City: __________ State: ____ Zip: _______

Reason for leaving: _______________________________________________________

Dates employed: From ______ to _______.

Volunteer Experience
o Do you have other volunteer experience? Yes ____ No ____

Please describe type and amount of previous experience:

Organization: ______________________________Dates of Service: From ____ to ____

Description of duties: ______________________________________________________

Organization: ______________________________Dates of Service: From ____ to ____

Description of duties: ______________________________________________________

o Community affiliations: (Name & indicate type of involvement)


Service Organizations_______________________________________________________

Professional Organizations/Boards_____________________________________________

Church __________________________________________________________________

Other ____________________________________________________________________

II. Skills and Interests
o What are your hobbies and/or special interests? _________________________________



o What specific skills and life experiences would you bring to CVDA as a volunteer?


o Specialized skills which you would like to contribute:
____ Phone calling ____ Equipment repair ____ Crafts
____ Word processing ____ Photography ____ Decorations
____ Mailings ____ Public Relations ____ Graphic Design
____ Computer tech. ____ Writing/editing ____ Entertainment
____ Errands ____ Fundraising ____ Speaking
____ Sign Language ____ Special Events - Specify: ___________________
____ Foreign Language - Specify: ____________________________________________
____ Other - Specify: ______________________________________________________

o Do you hold any special certificates? (e.g. CPR, First Aid, Lifeguard, Defensive
Driving). No ____ Yes ____ If yes, please indicate the type of license and an
expiration date ____________________________________________________________

III. Preferences in Volunteering:
o Upon reviewing our "Volunteer Opportunities, do you have a sense of an area at CVDA
you would like to be involved in? _____________________________________________


o Do you have any limitations (family commitments, health, etc.) which might affect
your volunteering? No ____ Yes ____ If yes, please explain. ______________________


o Have you ever been convicted of a criminal offense? No _____ Yes _____ If yes, please
explain: _________________________________________________________________

o Can you make a commitment to this program for at least a year? Yes ____ No ____
If no, please explain. ________________________________________________________

o At what times are you interested in volunteering?
Am flexible ____ Prefer weekdays ____ Prefer evenings ____
Prefer weekends ____ Prefer days ____ Other: ____________

If you are applying to volunteer in the “Friend-to-Friend” or “Circle of Friends” program, please answer the following questions:
o Is there a particular group with whom you are particularly interested?
No Preference ____ Developmentally disabled ____ Physically disabled ____

o Would you be comfortable volunteering with someone who is: ____ deaf; ____ blind;
____ wheelchair bound; ____ non-verbal; ____ development level much lower than their age.

o Is there any type of disability with which you would not feel comfortable working?
No ____ Yes ____ If yes, please specify: ______________________________________

~ Are you allergic to pets? ________ Please specify: ______________________
~ Do you smoke? __________ Are you willing to volunteer with someone who smokes? _____

o Do you have any geographic preference as to where you do volunteer work?
No ____ Yes ____ If yes, please specify: ______________________________________

IV. Transportation (Complete if this will be part of your volunteer service)
o Do you drive? No ____ Yes ____
If yes, are you willing to use your automobile for volunteer service? No ____Yes ____
(If yes, please attach a copy of your driver's license and proof of current auto insurance,
including passenger liability.)

o If you have had a moving violation or motor vehicle accident in the past 5 years, please describe._______________________________________________________________

o Have you ever have had any motor vehicle license suspended or revoked?
No ____ Yes ____ If yes, please describe: ____________________________________


IV. References and Background Checks:
o Please list three (3) people who are NOT CVDA STAFF or RELATED TO YOU
who know you well that we can contact for a reference check (May be school staff or faculty).

Personal References
1. Name: ________________________________
Nature of Relationship: _________________ Length of time known: ___________
Home phone (___)______________ Work phone (___)_________________

2. Name: ________________________________
Nature of Relationship: _________________ Length of time known: ___________
Home phone (___)______________ Work phone (___)__________________

Employer/Supervisor Reference (Someone you have worked with including employers
or supervisors in a paid or volunteer position. If you have never had a supervisor, please list
an additional personal reference)
1. Name: _____________________________ Work phone (____)________________

Title _______________________________ Length of time worked together _____

Business/Organization: _______________________________________________

I certify that the information set forth in this application is true and complete to the best of my knowledge. I understand that if I am accepted as a volunteer, Central Virginia Disability Association may end that relationship, if I have made any false statements or misrepresentations in this application. I authorize Central Virginia Disability Association to verify all information contained in or related to this application, including records of law enforcement agencies, references, employment and/or volunteer history.

I understand that information collected during this background check will be limited to that appropriate to helping determine my suitability for particular types of volunteer work and that all such information collected during the check will be kept confidential. I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their fill and honest evaluation of my suitability for the described volunteer work and such other information as they deem appropriate. (Questions asked during the reference check are available to review if you so choose.)

Signature: ________________________________________ Date: _____________________

Thank you for your time in completing this application!
We deeply appreciate your willingness to share yourself, your time and talents
with the persons CVDA serves and to experience their gifts in return.



Please print and mail or cut and paste to email your application to:

Central Virginia Disability Association, Inc. 
4321 Fort Avenue Lynchburg VA 24502

Phone: (434) 942-7682; E-mail: cvdisability@gmail.com