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2. 

3. Greene County Family Visitation Center

   143 East Market Street, Xenia, Ohio 45385

   (937)-562-5687

   Fax: (937) 562-5691

   Email: gcvc@greenecountyohio.gov

5. Interns and Volunteers must have a willingness to help the children and families of Greene County, have good communication skills, and the ability to work well with children of all ages.
7. I am interested in

   1. a volunteer position
   2. an internship position (unpaid)
8. Date:
10. First & Last Name:
12. Street Address:
14. Email Address:
15. Date of Birth:
17. Driver's License Number:
18. State Issuing Driver's License:
20. Phone Number Daytime:
21. Phone Number Evening:
22. Cell Number:
24. Emergency Contact Person:
25. Phone Number:
27. Please list three professional references (other than relatives). List individuals who have knowledge about your skills and abilities, such as; co-workers, a volunteer supervisor, a pastor, academic professional, etc.:
29. 1) Name, Mailing Address or Email Address, Phone number:
31. 2) Name, Mailing Address or Email Address, Phone number
33. 3) Name, Mailing Address or Email Address, Phone number
35. Formal Education (highest year of school completed):
36. Degrees or Majors:
38. Do you speak a foreign language?

    1. YES
    2. NO
39. If YES, which languages?
41. Have you ever been convicted of a crime, other than a traffic violation?

    1. YES
    2. NO
42. If YES, what was the charge?
43. Date Convicted:
44. What State/County?
46. Do you consent to a routine check of your criminal record (if necessary)?

    1. YES
    2. NO
47. Have you lived in Ohio for the past 5 years?

    1. YES
    2. NO
49. Please list current and previous volunteer work, clubs, and community organizations, including a brief description of the duties and activities you were involved in. Additionally, please add your dates of service.
51. Have you been involved professionally or personally with the following programs/agencies?
53. Children Services Board (CSB)?

    1. YES
    2. NO
54. Foster Care?

    1. YES
    2. NO
55. Court System?

    1. YES
    2. NO
56. CASA?

    1. YES
    2. NO
58. Other agencies offering services to children?

    1. YES
    2. NO
59. If YES to any please explain:
61. How did you learn about our program?
63. Do you have any particular skills or hobbies that you would be specifically interested in sharing with the Visitation Center or our families?
65. Employment History (beginning with current):
67. 1) Employer's Name & Address:
69. Job Title:
70. Start Date & Ending Date:
72. Job Duties:
74. Supervisor's Name & Phone Number:
76. 2) Employer's Name & Address:
78. Job Title:
79. Start Date & Ending Date:
81. Job Duties:
83. Supervisor's Name & Phone Number:
85. 3) Employer's Name & Address:
87. Job Title:
88. Start Date & Ending Date:
90. Job Duties:
92. Supervisor's Name & Phone Number:
94. I certify that the statements herein contained are true to the best of my knowledge. I understand that any question contained herein, or failure to completely answer any question contained herein, is cause for dismissal from service to Greene County Visitation Center. I further understand that a record check with police agencies may be conducted as part of the application process, and I give Greene County Visitation Center permission to make such a check in order to ensure my suitability for volunteer placement.
96. I understand and agree that Greene County Family Visitation Center may make a thorough investigation of my past employment and activities, and I release from liability or responsibility all persons and organizations supplying such information. I also understand and agree that the information obtained may be used by Greene County Family Visitation Center in any way connected with my involvement in the program.
98. Signature:
99. Date:
Leave This Blank:


101. 1. Receive an email copy of this form.
102. Email address

     This field is not part of the form submission.

103. Submit

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