Volunteer Form Please fill out the entire form below then submit. If you have any questions call 316.660.0600. Are you a member?*Select valueYesNoName:* Title First Last Name preferred for badge:DOB:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 2015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearHome Address:* Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryPrimary Phone:* Area Code - Phone Number Type:*Select valueHomeCellWorkSecondary Phone: Area Code - Phone Number May we leave messages for you or call you at work if we need to contact you on short notice? *YesNoE-mail Address*Do you have previous volunteer experience?*YesNoList up to three places you have volunteered and what kind of volunteering activity you preformed there:Example: 1. Exploration Place - I assisted with summer camp activities and groups of up to 30 children. 2. Place You Volunteered - activities you preformed 3. Place you Volunteered - actiities you preformedDo you know any foreign languages or ASL? (Please list)*Please list two work, school, or personal references, not relatives, whom we may contact regarding your application.1st Contact Name:*Relationship:*Address:123 N. AnyStreet City, State 000000Contact Phone:* Area Code - Phone Number Phone Type:*Select valueHomeCellWork2nd Contact Name:*Relationship: *Address: 123 N. AnyStreet City, State 000000Contact Phone: * Area Code - Phone Number Phone Type: *Select valueHomeCellWorkHighest year completed or current year in school? *Please Select10th Grade11th Grade12th Grade1st Year College2nd Year College3rd Year College4th Year College5+ Years CollegeHighest degree earned:*Major:*Name of School:*List any other formal training, skills, or experience that might be pertinent to volunteering at Exploration Place:*Medical Emergency Information1st Contact Name:(1)*Relationship:(1)*Contact Phone:(1)* Area Code - Phone Number Phone Type:(1)*Select valueHomeCellWork2nd Contact Name:(1)*Relationship: (1)*Address: (1)123 N. AnyStreet City, State 000000Contact Phone: (1)* Area Code - Phone Number Phone Type: (1)*Select valueHomeCellWorkPersonal Physician:*Phone:* Area Code - Phone Number Hospital Preference:*Please list any allergies, special medical needs or conditions that would be relevant during emergency situations:It is the policy of Exploration Place to comply with all applicable state and federal laws prohibiting discrimination in employment/volunteering based on race, religion, color, sex, age, national origin, disability or any other protected classification.Employment HistoryI am (check one):EmployedUnemployedRetiredEmployer:Occupation:Please complete this section of the form as it is applicable to your employment situation:Employer Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountrySupervisor Name:May we contact you at work?:Select valueYesNoWould you like us to keep your employer informed of your volunteer services? :Select valueYesNoDoes your employer offer a time-off program for volunteers?:Select valueYesNoDoes your employer (Or former employer if retired) offer a donation matching program? :Select valueYesNoHave you ever been employed at Exploration Place? :Select valueYesNoIf yes, when:Position:Do you have friends or relatives currently employed or volunteering at Exploration Place?:Select valueYesNoPlease list name and relationship:I certify that the answers given herein are true and complete to the best of my knowledge. I authorize an investigation of all statements contained in this application as may be necessary in arriving at an acceptance decision. In the event of acceptance, I understand that false of misleading information given in my application or interview may result in dismissal form the volunteer ranks. I am aware that acting as a volunteer does not make me an employee of Exploration Place. I understand, also, that I am required to abide by all rules and regulations of Exploration Place. As a volunteer, I agree to hold as absolutely confidential all privileged, and sensitive information which I may obtain directly or indirectly concerning Exploration Place, its guests and staff (including employees and volunteers).I authorize Exploration Place to receive information from the Kansas Bureau of Investigation and any law-enforcement agency, including police departments, and sheriff's departments, of this state or any other state or federal government, to the extent permitted by state and federal law, pertaining to any convictions I may have had for violations of state or federal criminal laws, including but not limited to convictions from crimes committed upon children. I understand that such access is for the purpose of my application as a volunteer, and that I expressly DO NOT authorize Exploration Place, its directors, officers, employees or volunteers to disseminate this information in any way to any other individual, group, agency, organization or corporation.I certify that I have read and agree to the statements above.Signature:Date:Applicant is under 18. He/She has my permission to become a volunteer at Exploration Place. Parent/Guardian Signature:Date (1):Authorization to Release Information. Please print this document, fill out, scan and send to volunteers@exploration.org. Forms also can be dropped off in person during normal business hours at the Ticket Counter, or mailed to. Exploration Place Att: Volunteer Coordinator 300 N. McClean Bvld. Wichita, Ks 67203SubmitReset
