**PLEASE fill out and print

Valley AIDS Information Network, Inc.
PO Box 971, Corvallis, OR 97339-0971
(541) 752-6322
www.ValleyAIDSInfo.org

HIV/AIDS, Hepatitis C, and STI's

Information, Support, Referrals and Speakers

Application to: Volunteer Intern - # hours required

Community Service - # hours required

Valley AIDS Information Network, Inc. (VAIN) is excited that you are interested in becoming a volunteer or Intern. We will do our best to match your areas of interest with our current volunteer opportunities. Please PRINT out and answer all questions if more room is needed, add additional pages. You can also SCAN this completed application and send to Volunteer@valleyAIDSInfo.org

These questions will help us find a mutually rewarding team position. Should you have any questions please contact: VAIN’s Volunteer Coordinator at 541 752-6322 or by email: Volunteer@ValleyAIDSInfo.org

Personal Information

First Name M/I Last Name

Address

City     Zip Code

Email Address

Date of Birth: yyyy/mm/dd

 

Home Phone Cell Phone Work Phone

Emergency Contact Name

Relationship

Emergency Contact’s Phone

Gender:

Ethnicity:

Why would you like to volunteer with VAIN?

How often are you available? Daily Weekly Bi-Weekly Monthly

What days are you available?
Time available?  Mornings    Afternoons    Evenings  Other_________

Do you speak Spanish?
Do you have a valid Drivers License State:
Do you have Insurance?

Have you previously volunteered, or worked for any non-profit organizations?
If yes,
Name
Address
City State Zip
Supervisors Name
Phone Number
Start Date (yyyy/mm/dd) End Date (yyyy/mm/dd)
Your Title

Have you personally helped or worked directly with any persons who were either HIV-positive or had an AIDS diagnosis?
If yes, please describe


Do you have experience with special needs clients?
Please Explain

Please select each type of Client you have experience working with:
Alcoholic(s) Drug Addict(s) IV Drug Users Homeless
Undocumented Immigrant(s) Incarcerated Individual(s)
High Risk Youth High Risk Adults MSM (men who have sex with men)
Other:

Please read VAIN’s current Volunteer opportunities and list specific position(s) you would like to apply for:

What experience or skills do you have that will help you volunteer at VAIN?

Scholastic Achievements

School:
High School Graduate?
Degree(s) or Certificates Earned:

Other Degree(s) or Certificate(s) Obtained:

Current Employment

I am Currently Employed:
Current Position/Title
How long Name of Employer
Address
City State Zip
Phone

Personal References

Name:
Relationship: Phone

Name
Relationship Phone

Where did you here about VAIN? School Work TV Radio Family Friend Other (please list)

Confidently Policy:

From time to time people seeking assistance from VAIN, while accessing resources, referrals, information, or assistance, will disclose their HIV status, medical condition(s), medical treatment, history of drug or alcohol treatment, sexual orientation, or gender identity to members of VAIN. I understand that VAIN’s highest priority in these instances is the assurance of the confidentiality of the organization’s clients and volunteers in regards to their personal information. Under no circumstances will I divulge the personal information of anyone who contacts or otherwise utilizes VAIN and its resources or programs. In the extraordinary event that it becomes necessary to reveal this information, I will first consult with a member of VAIN’s Board of Directors. I understand that violation of this policy, i.e., “outing” a client or VAIN volunteer, without his/her prior permission, or the permission of a member of VAIN’s Board of Directors, may result in an investigation by the Board of Directors, and the findings may result in possible termination or even prosecution as applicable under Oregon and Federal law.

Equal Opportunity & Discrimination Polices: Volunteer opportunities are open to all qualified applicants, solely on the basis of their interest, experience, knowledge, skills and abilities. Qualified applicants are considered for all open positions for which they apply and for advancement without regard to race, color, religion, gender, gender expression, sexual orientation, national origin, age, marital status, or the presence of a medical condition or disability. VAIN will not tolerate any form of discrimination, harassment or retaliation affecting its clients, volunteer’s or applicants due to race, color, religion, gender, gender expression, sexual orientation, national origin, age, marital status, medical condition, or disability.

By affixing your signature, you hereby understand and agree to abide by both VAIN Confidentiality & Discrimination Policies.

Applicants Signature

Date

Witnessed By  Date

revised 1/26/2015