To Volunteer, submit the following form electronically. If you have any questions, please contact Linda J. Proffitt, Program Director, at lproffitt@agscleveland.org or call 216-696-1132, ext. 141. Adult Guardianship Services, Volunteer Department, 1468 W. 25th Street, Suite 300, Cleveland, Ohio 44113

Name:
Address:
City: State: Zip:
Home Phone:
(with area code)

Work Phone: (with area code)
Email Address:
Birth Date:
(for recognition purposes only)
Employment History:
Employer:
Position:
From/To:
(dates)
Employer:
Position:
From/To:
(dates)
Employer:
Position:
From/To:
(dates)
Volunteer Positions
Organization:
Position:
From/To:
(dates)
Organization:
Position:
From/To:
(dates)
Organization:
Position:
From/To:
(dates)
Person to contact in case of an emergency:
Name:
Address:
City: State: Zip:
Home Phone:
(with area code)

Work Phone: (with area code)
Any Religious Affiliations:
Yes No (optional) If yes, please specify
Do you drive a car?
Yes No
Do you have a valid driver license?
Yes No
Driver's License number and stae where issued:
Number State
Do you have automobile insurance?
Yes No
Proof of automobile insurance must be provided prior to being approved as a guardian, guardian assistant, or other volunteer.
If you have no access to a car, do you have access to public transportation?
Yes No

References

List four non-family member references that we can contact. At least two of these should be business or professional. Please inform your references that you have given their names so they will be expecting contact from our office.
Name:
Address:
City: State: Zip:
Phone:
(with area code)

Known How Long?
Relationship:
Name:
Address:
City: State: Zip:
Phone:
(with area code)

Known How Long?
Relationship:
Name:
Address:
City: State: Zip:
Phone:
(with area code)

Known How Long?
Relationship:
Name:
Address:
City: State: Zip:
Phone:
(with area code)

Known How Long?
Relationship:
List any language that you speak in addition to English. Also note if you are skilled in sign language for communicating with the hearing impaired.
Why do you want to volunteer for Adult Guardianship Services?
Describe any personal or professional experience you have working with mentally impaired adults or agencies serving them.
According to the laws of the State of Ohio, an applicant charged with or convicted of a crime involving theft, physical violence, or sexual, alcohol or substance abuse usually will not become a Court appointed guardian. Have you ever been charged with or convicted of any such crimes? Yes No
(If yes, please list the date and place of each charge and conviction. If none, please state NONE.)

Please Read Carefully

I understand that completion of this application does not indicate whether there are any positions currently open and that it does not obligate the agency to extend association on a volunteer basis. All of my responses to the above questions are true and I give my permission for my references to be contacted. The above information and any further information will be used in determining my suitability as a volunteer. A copy of this application may be supplied to Probate court if the court requests it. Otherwise, all information will be confidential. My signature on this application does not commit me to volunteering at this time but is completed as a statement of my interest and intent. All individuals will be considered regardless of race, color, religion, national origin, sex, or marital status. I understand that if I commit to being a volunteer guardian, I may need to be bonded.

I further understand that the agency will verify my criminal record and my driving record and, by signing below, I give my full consent to such verification.


Signature


Date
How did you hear about our program?

Date Completed:

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