The document is a volunteer application for the Bully Prevention Alliance. It requests basic contact information, availability, interests and skills. It also asks about prior volunteer experience, references, criminal history and permission to conduct background/driving checks. Applicants can choose to allow or deny the use of photos for publicity. By signing, applicants affirm they answered truthfully and understand intentionally false information could deny them volunteer rights.

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Bully Prevention Alliance
Volunteer Application
Please print clearly and fill out the application completely
Name (first, middle, and last) ______________________________________________
Home Address _________________________________ Apt/Suite _______________
City ________________________ State _________________ Zip _______________
Phone Numbers __________________ ___________________ _________________
Cell Home Work
Best time to call: ________________________
Email ____________________________________________________________
Preferred Method of Communication (please circle): Cell Home Work Email
Male ( ) Female ( ) Date of Birth ________________________________
Social Security Number (needed for background check) _________________________
Current Employer ____________________________ Position ___________________
Work Address __________________________________________________________
City __________________________ State ______________ Zip ________________
Why are you interested in volunteering with the Bully Prevention Alliance (if you need
additional space please use the last page)?
© 2011. U.S. Bully Prevention Alliance. Indianapolis, Indiana.

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How did you hear about the Bully Prevention Alliance? ( ) Word of Mouth ( ) Other –
Please describe _______________________________________________________________
I would like to be considered for the following volunteer opportunities (select all that
apply):
( ) School Activities ( ) Special Events ( ) Office Help ( ) Other – Please describe
___________________________________________________________________
___________________________________________________________________
Please list any languages that you speak, read, and/or write fluently in addition to
English:
______________________________________________________________________
Have you volunteered for other organizations? _____ Yes _____ No (If you checked
Yes, please continue below)
Organization Name: _____________________________________________________
Dates of Service: _______________________________________________________
Describe volunteer service:
Organization Name: _____________________________________________________
Dates of Service: _______________________________________________________
Describe volunteer service:
© 2011. U.S. Bully Prevention Alliance. Indianapolis, Indiana.

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Please describe any work experience you think might be relevant to our program:
Do you have any hobbies or special talents that you may be able to offer as a
volunteer?
What age group do you enjoy working with the most: (You can circle more than one
group below)
Youth (ages 6 – 12) Teens (ages 13 – 18) Adults (18 & older)
Please list three references:
______________________________________________________________________
Name Relationship Time Known Phone Number
______________________________________________________________________
Name Relationship Time Known Phone Number
______________________________________________________________________
Name Relationship Time Known Phone Number
Have you ever been charged with or convicted of the following: (please check yes or no)
a) Felony _____ Yes _____ No
b) Any crime involving a sexual offense, an assault, or the use of a weapon?
_____ Yes _____ No
c) Any crime involving the use, possession, or the furnishing of drugs or hypodermic
syringes? _____ Yes _____ No
d) Reckless driving, operating a motor vehicle while under the influence, or driving
to endanger? _____ Yes _____ No
© 2011. U.S. Bully Prevention Alliance. Indianapolis, Indiana.

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If you answered “Yes” to any of the previous four items, please explain:
Bully Prevention Alliance has my permission to: (please check below)
Run a background check on me: _____ Yes _____ No
Run a motor vehicle records check on me if I decide to operate a vehicle on behalf of
the Bully Prevention Alliance: _____ Yes _____ No
Verify the three references I have provided: _____ Yes _____ No
Release for Publication (please initial below)
While you are serving as a volunteer for Bully Prevention Alliance, there will be
occasions when you may be photographed and/or videotaped by staff, sponsors,
corporate representatives, media, and others. We request permission for your
participation. By initialing below, you may choose to grant or deny Bully Prevention
Alliance permission to use photographs or videotapes of yourself, alone or in groups, in
newspaper articles, newsletters, web site, brochures, special fundraising activities,
scrapbook, videos and photo albums for use in public understanding and support of
Bully Prevention Alliance’s activities and program. By granting permission below, you
hereby release and hold harmless Bully Prevention Alliance from any claims, judgments
or demands which may arise from the use of the above referenced photographs and/or
videotapes.
Please initial your selection below:
_________ Yes, I give my permission for participation as described above
_________ No, I deny consent for participation as described above.
By signing below, I affirm that I have answered all questions truthfully. I understand that
if any portion of this application is found to be intentionally false, I may be denied the
right to volunteer for Bully Prevention Alliance.
__________________________________________ _____________________
Your Signature Date
© 2011. U.S. Bully Prevention Alliance. Indianapolis, Indiana.

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© 2011. U.S. Bully Prevention Alliance. Indianapolis, Indiana.