Barrington Junior Women's Club

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Safety Town 2008 Volunteer Application

All registration form fields noted with * are required.

Current Session Status as of 5/20/08

Sessions 1-2: June 16 thru June 27

Sessions 3-4: July 14 thru 25

-  CLOSED  -

Session 3:  9:00 a.m. - 11:30 a.m. (2 spots open)

-  CLOSED  -

Session 4:  12:30 p.m. - 3:00 p.m. (4 spots open)

Please ask one teacher to prepare a note supporting their belief that you will be a good volunteer and will follow the Volunteer Code of Conduct during your Safety Town Volunteer participation.

 No  Yes  Teacher's signature acquired.*    Name of Teacher:           *

 

I wish to register as a Safety Town Volunteer and agree to abide by the Safety Town Volunteer Code of Conduct.  I will be enrolled in              at          School in August 2008.  My choice(s) for Session assignment are (you may volunteer once in June and once in July if you wish):

My FIRST CHOICE for a session assignment is:                    *

My SECOND CHOICE for a session assignment is:               *

My THIRD CHOICE for a session assignment is:                    *

First Name:         *

Last Name:         *

Address:             *

City:  *  State:         *  Zip:        * 

Township:  *

Birth Date:         /       /          *    Gender:        *

Home Phone:     --*

Email Address:      *

Mother’s First Name:    *

Mother’s Last Name:          *

Work #:           --

Mobile#:  --

 

Father’s First Name:           *

Father’s Last Name:           *

Work #:           --

Mobile #:    --

 

Email: May we email you Safety Town reminders or updates?              YES   NO *

List persons whom Safety Town may call if parents are unavailable in case of an emergency:

Name:             *  Phone:           --*

Name:             *  Phone:           --*

We try to accommodate requests for volunteers to be scheduled in the same session. Is/are there any friends you would like to volunteer?

Volunteer:  

Volunteer:  

Volunteer:  

Does you have any special needs that we should be aware of? If no special needs, please indicate “None”:

Name of your:

Physician:                   *

Address:                   *

Phone:                     --*

Dentist:                   *

Address:                   *

Phone:                     --*

Is your mother a member of BJWC?    YES   NO *

Have you been a volunteer before?    YES   NO *    When? 

Parent Review and Consent Required

Barrington Junior Women’s Club,Inc. is a 72-year old philanthropic organization with 501(c)3 status. Membership includes 200 plus area women of all ages committed to community service. Through extensive fund-raising, BJWC provides grants to over 25 area charitable and educational organizations as well as scholarships. In addition to Safety Town, BJWC operates and funds “Kids on the Block” and offers hands-on volunteerism to area organizations, seniors and families.

In case of accident or sickness of my child while under the care and supervision of Safety Town, the undersigned hereby gives consent to provide emergency care and/or treatment through a clinic, hospital or private doctor. I give my consent for X-rays, if the hospital/doctor determines it is advisable. I agree to pay all costs and fees contingent upon any emergency care and treatment for my child as secured or authorized under this consent. This agreement shall continue as long as the above named child is enrolled in the program.

I agree to the above consent conditions.  No  Yes*

As a parent, I agree to support my child’s participation and to ensure they abide by the Code of Conduct.

I agree to the above permission conditions. No  Yes*

Please complete my application as a Safety Town Volunteer No  Yes*

In a brief paragraph, please explain why you would like to be a Safety Town volunteer.

 

In a brief paragraph, please let us know what you think you will learn from your Safety Town Volunteer experience.

 

Please press the Submit Button when you have filled in all of the information.