ࡱ> '` 0bjbj{P{P "::H-$(777P79*(:F VCVCVCVC0H,\PTH$Rh)~tG^G^~~VCVC{{{~8VC<8VC{~{{V@$tVC: Pgӣ7ы IL0*݋ B/(BB`0W d {n~v)0W0W0WW$0W0W0W*~~~~ 664@$  FORMTEXT        FORMTEXT        FORMTEXT       Last Name First Middle  FORMTEXT       Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT       City State Zip Please check the best way to be contacted:  FORMCHECKBOX  Day Phone ( FORMTEXT       )  FORMTEXT        FORMCHECKBOX  Evening Phone ( FORMTEXT       )  FORMTEXT        FORMCHECKBOX  Cell Phone ( FORMTEXT       )  FORMTEXT        FORMTEXT       E-mail Address  FORMTEXT       Social Security Number  FORMTEXT       Date of Birth  FORMTEXT       Driver s License Number  FORMTEXT       Other states of residence in past five years Are you 18 or over?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you currently a member of Girl Scouts?  FORMCHECKBOX  Yes  FORMCHECKBOX  No What type of volunteer service interests you?  FORMCHECKBOX  Advisor/Leader  FORMCHECKBOX  Office/clerical work  FORMCHECKBOX  Other support to girls  FORMCHECKBOX  Training adults  FORMCHECKBOX  Fund-raising  FORMCHECKBOX  Outdoor program  FORMCHECKBOX  Marketing  FORMCHECKBOX  Activity/Program presenter  FORMCHECKBOX  Computer/Website  FORMCHECKBOX  Community organization  FORMCHECKBOX  Public Relations/public speaking  FORMCHECKBOX  Occasional opportunities to work with girls  FORMCHECKBOX  Organizing Special Events  FORMCHECKBOX  Other  FORMTEXT       List any specialized skills:  FORMTEXT       Language skills other than English:  FORMTEXT       Why are you interested in a Girl Scout volunteer position?  FORMTEXT       Grade groups preferred (if relevant to position)  FORMCHECKBOX  Grades K - 1  FORMCHECKBOX  Grades 2 - 3  FORMCHECKBOX  Grades 4 - 5  FORMCHECKBOX  Grades 6 - 8  FORMCHECKBOX  Grades 9 - 10  FORMCHECKBOX  Grades 11 - 12  FORMCHECKBOX  Adult Location, time available or other preferences:  FORMTEXT       School (if applicable)  FORMTEXT       Daughter s Name (if applicable)  FORMTEXT       Employment Experience (list most recent first) Please provide accurate and complete information for all employment (including temporary, part-time, self-employment and unemployment for the past five years). Attach additional sheets if necessary.  FORMTEXT       Organization Name  FORMTEXT        FORMTEXT       Dates employed (to and from) Position  FORMTEXT        FORMTEXT       Supervisor s Name Phone #  FORMTEXT       Organization Name  FORMTEXT        FORMTEXT       Dates employed (to and from) Position  FORMTEXT        FORMTEXT       Supervisor s Name Phone # Volunteer Experience (List previous Girl Scout or other youth service first.) Please provide accurate and complete information for all volunteer experience for the past five years. Attach additional sheets if necessary.  FORMTEXT       Organization Name  FORMTEXT        FORMTEXT       Dates of Volunteer Service (to and from) Position  FORMTEXT        FORMTEXT       Organization Contact Person Phone #  FORMTEXT       Organization Name  FORMTEXT        FORMTEXT       Dates Volunteer Service (to and from) Position  FORMTEXT        FORMTEXT       Organization Contact Person Phone # How did you learn about Girl Scout volunteer opportunities?  FORMCHECKBOX  School  FORMCHECKBOX  Brochure  FORMCHECKBOX Girl Scout volunteer  FORMCHECKBOX  Employer  FORMCHECKBOX  Media  FORMCHECKBOX  Girl Scout staff  FORMCHECKBOX  Website  FORMCHECKBOX  Other Educational Background Educational Institution:  FORMTEXT       Highest Year Completed:  FORMTEXT       Degree/Credits:  FORMTEXT       Educational Institution:  FORMTEXT       Highest Year Completed:  FORMTEXT       Degree/Credits:  FORMTEXT       GED (General Equivalency Diploma)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Other Training and Cert. Completed Date Expires  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Please indicate any other names you have used that may be necessary for us to verify the information on this application.  FORMTEXT       References List three people (non-relatives) who are familiar with your qualifications for Girl Scout service:  FORMTEXT        FORMTEXT       Name Relationship  FORMTEXT       Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT       City State Zip  FORMTEXT       Day Phone Evening Phone  FORMTEXT       E-mail Address  FORMTEXT        FORMTEXT       Name Relationship  FORMTEXT       Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT       City State Zip  FORMTEXT        FORMTEXT       Day Phone Evening Phone  FORMTEXT       E-mail Address  FORMTEXT        FORMTEXT       Name Relationship  FORMTEXT       Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT       City State Zip  FORMTEXT        FORMTEXT       Day Phone Evening Phone  FORMTEXT       E-mail Address Have you ever been convicted of a crime (e.g., felony or misdemeanor including DWI, DUI, etc., but not including minor traffic violations or any convictions as a youthful offender)? A conviction will not necessarily bar your acceptance as a volunteer.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes please explain place, date and disposition of any conviction:  FORMTEXT       This is an application for a volunteer position in Girl Scouting for which there is no monetary compensation. In the selection of volunteers, there shall be no discrimination against an otherwise qualified individual on the basis of race, color, ethnicity, sex, religion, creed, national origin, socioeconomic status, age, disability, marital status, veteran status or any other basis prohibited by federal, state or local law. I hereby authorize you to check all of my educational, personal and employment references. I further authorize these references to release to you information that they have about me. I authorize the Girl Scouts Heart of the South to conduct a criminal records check and agree that, if requested, I will fully cooperate in providing all information and signing of documents necessary to conduct such a check. I understand that any misrepresentation, omission or falsification of any fact from this application or during any interview will be cause for rejection of this application or dismissal from volunteer services. I also understand that acceptance for volunteer services are subject to verification of references.  FORMTEXT        FORMTEXT       Signature Date Please return completed application via mail or fax to:  FORMCHECKBOX  Girl Scouts Heart of the South Columbus Service Center P. O. Box 2492 Columbus, Mississippi 39704 F (662) 328-1220 Attn:  FORMTEXT        FORMCHECKBOX  Girl Scouts Heart of the South Corinth Service Center P. O. Box 1145 Corinth, Mississippi 38835 F (662) 286-8142 Attn:  FORMTEXT        FORMCHECKBOX  Girl Scouts Heart of the South Greenwood Service Center P. O. 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O. Box 240246 Memphis, Tennessee 38124 F (901) 797-2183 Attn:  FORMTEXT        FORMCHECKBOX  Girl Scouts Heart of the South Tupelo Service Center P. O. Box 1087 Tupelo, Mississippi 38802 F (662) 680-3164 Attn:  FORMTEXT        For Office Use Only Application reviewed by Date Paid Membership ($12) Background Check Completion Date Service Unit Regional Service Centers Columbus, MS  662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS  662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834( Mailing:P. O. Box 1145, Corinth, MS 38835 Grenada, MS  662-226-0255 or 888-453-2034(FAX: 662-226-0258(2430 Sunset Drive Ste D, Grenada, MS 38901 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy, Ste 1, Mphs, TN 38119(Mailing: PO Box 240246, Memphis, TN 38124 Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. Box 1087, Tupelo, MS 38802 Website:  HYPERLINK "http://www.girlscoutshs.org" www.girlscoutshs.org Girl Scouts Heart of the South   Background Check Authorization and Consent for Release of Information  I understand that the preappointment background check requires my full name, date of birth, driver s license number, and Social Security Number. I understand that the information I have provided may be verified by contacting persons or organizations listed in this application, or by contacting any person or organization that may have information concerning me. I hereby consent and voluntarily authorize Girl Scouts Heart of the South to obtain an independent criminal background report and Social Security Number validation report. I further authorize said council to request or receive information including motor vehicle reports, past employment and education records, and/or references from any persons, schools, or previous employers only if pertinent to my potential work as a volunteer. I further understand that a credit report may be requested if my assignment includes the handling of money. I certify that the entries made by me in this form are true, complete, and accurate to the best of my knowledge, and are made in good faith and voluntarily. I understand that any false statements or answers by me may disqualify me for volunteer services or will be sufficient grounds for termination. Moreover, I understand that failure to complete this form will preclude me from volunteer opportunities with the Girl Scouts Heart of the South. I further understand that I will receive a complete and accurate disclosure of the nature and scope of the background verification, in the event such investigation negatively affects my placement as a volunteer. Signature  FORMTEXT       Date  FORMTEXT       After the background check is completed, the information below will be destroyed. Print your name here  FORMTEXT       Driver s License Number  FORMTEXT       Social Security Number  FORMTEXT       Date of Birth  FORMTEXT       Regional Service Centers Columbus, MS  662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS  662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834( Mailing:P. O. Box 1145, Corinth, MS 38835 Grenada, MS  662-226-0255 or 888-453-2034(FAX: 662-226-0258(2430 Sunset Drive Ste D, Grenada, MS 38901 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy, Ste 1, Mphs, TN 38119(Mailing: PO Box 240246, Memphis, TN 38124 Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. Box 1087, Tupelo, MS 38802 Website:  HYPERLINK "http://www.girlscoutshs.org" www.girlscoutshs.org     Regional Service Centers Columbus, MS  662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS  662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834(Mailing: P. O. Box 1145, Corinth, MS 38835 Greenwood, MS  662-453-2034(FAX: 662-453-2035(305 East Washington Street, Greenwood, MS 38935(Mailing: P. O. Box 1816, Greenwood, MS 38935 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy, Ste 1, Memphis, TN 38119(Mailing: P. O. Box 240246, Memphis, TN Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. 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