Basic Requirements:

 Must be at least 13 years of age (under 18 must have parental consent).

 Prior experience working with individuals from diverse backgrounds.

 A willingness to invest your time to serve and assist in the community.

 All individuals over 18 yrs must consent to a criminal background check.

 Possess patience and excellent communication skills.

Please complete the entire form below.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

School Name & Highest Grade Completed

Are you at least 18 yrs old?

Yes

If not, please provide parent's/guardian's name.

Employer's Name & Occupation

Do you have any prior volunteer experience?

Yes

If so, please list experience below.

Agency. Position. Dates.

Please provide two personal and one professional reference.

Name. Relationship to you. Number. Email Address.

Have you ever been convicted (found guilty) of a crime (including probation(s) before judgment), or are there any pending criminal charges awaiting a hearing in a court of law? Do not list any criminal charges for which records have been expunged.

Yes

If you answered YES, please describe all convictions, when they occurred, the facts and circumstances involved, and information pertaining to rehabilitation.

Statement of Understanding: I certify that all information is true and has been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest. I release The Butterfly Effect, Inc. from any liability whatsoever for supplying such information. I understand that I must be at least 13 years of age to volunteer for any events and if I am under the age of 18 years of age and/or attending high school I will need parental consent. Upon being offered a volunteer position, I understand that I may be required to provide additional information pertinent to the position for which applied.

I understand.