Signal Centers Volunteer Application Form

Date

MonthDayYear
Date
Applicant/Company Representative Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Email*
example@example.com
Gender
Date of Birth*

MonthDayYear
Date
Race
Organization you represent (If applicable)
Are you a citizen of the United States?*
If no, are you authorized to work in the U.S.?
Have you ever been convicted of a criminal offense (felony or misdemeanor)?*
If yes, please explain

Experience
Please tell us about any relevant volunteer interests/skills:*

Availability
How many hours would you like to volunteer each week/month?
What day(s) are you available to volunteer? Please check all that apply.

MondayTuesdayWednesdayThursdayFriday
What hours are you available to volunteer?
Is there a specific program in which you would like to volunteer?

Emergency Contact Information

Please add two emergency contacts.
Contact 1 Name*
Address
Work Phone
Mobile Phone
Relationship to applicant
Contact 2 Name*
Address
Work Phone
Mobile Phone
Relationship to applicant

References

Please add the contact information for two references (personal or professional) and we will send them Statement of Reference forms to fill out. We recommend following up with your contacts to ensure they received and have filled out the form as you will not be able to fulfill your volunteer placement without completed references.
Name

First NameLast Name
Email
example@example.com
Name

First NameLast Name
Email
example@example.com

Video Training

If you are interested in volunteering with Adult Day Services or Children's Services, please watch these mandatory training videos and sign the acknowledgement form below.
Volunteering with Adult Day Services
Volunteering with Children's Services
If you use a screen reader and are the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of Applicant

Clear
Date

MonthDayYear
Date

Notification/Authorization for Procurement of Consumer Reports

This acknowledgement allows Signal Centers to perform a Background Check on the volunteer applicant.
Driver's License State (e.g. GA, TN)*
Driver's License Number*
Social Security Number*
Please list every city and state in which you have lived in the last seven years.*
City, State
City, State
City, State
City, State
City, State
City, State

Volunteer Handbook Receipt Acknowledgement
Signal Centers Volunteer Handbook

Fingerprinting Process Instructions
1. Go to www.identogo.com and choose Tennessee.

2. Under “Enrollment Services” select “Digital Fingerprinting”.

3. Select “Schedule a New Appointment”.

4. Enter service code as supplied by agency. If you do not have a service code, select “Don’t Know Your Service Code” and then choose the agency for which you are being fingerprinted from the drop-down list and then select your applicant type.

5. Select: “Don’t know Service Code”, Agency: Health Care, Type: Health Service Volunteer

6. Enter any applicable information such as ORI, OCA, provider ID (requirements vary based on agency and reason fingerprinted) ORI: TNHS00083

7. Read acknowledgement and select the “I Agree” box. Click “GO”.

8. Enter personal zip code to determine the closest printing location.

9. Choose the location at which you would like to be printed, view schedule and select an appointment date/time.

10. Enter required demographic information.

11. Verify that all information is correct.

12. Select method of payment and click “Send Payment Information.” If you are paying with a coupon code, you must bring the coupon code to your appointment.

13. No coupon code.

14. Bring approved identification documents with you to the appointment. This includes the confirmation page you received after booking your appointment. These approved document options are identified on your confirmation page.

15. Arrive at the facility at your appointed date and time.

16. The Enrollment Officer at the site will check your ID, verify your information, verify or collect payment, capture your fingerprints, and submit your data. This normally takes less than five minutes.

17. You will receive a signed receipt at the end of your fingerprinting session which can be provided to your agency for proof of fingerprinting. Please give your receipt to the Volunteer Coordinator at Signal Centers, you will be reimbursed for fingerprinting costs.

18.All results will be processed and delivered to your employment or licensing agency for processing by the TBI. Idemia is never in possession of criminal record data results.

Disclaimers, Agreements, and Consent Forms

Please review each section carefully.
If you use a screen reader and are the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of Applicant

Clear
Date

MonthDayYear
Date
If you use a screen reader and are the parent/guardian of the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of parent/guardian (If applicant is under 18)

Clear
Date

MonthDayYear
Date
Should be Empty:

Experience

Availability

Emergency Contact Information

References

Video Training

Notification/Authorization for Procurement of Consumer Reports

Volunteer Handbook Receipt Acknowledgement

Fingerprinting Process Instructions

Disclaimers, Agreements, and Consent Forms