Service Learning Application

Full Legal Name *

for purpose of background check: please include First, Middle, and Last name(s)

Preferred Name

Other Names Used

Including unmarried name if applicable

What School Do You Attend? *

Date of Birth *

00/00/0000

Email Address *

Address

City

State

Zip Code

How long have you lived at this address? *

this information is required for the background check process

Phone *

(000) 000-0000

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone Number *

(000) 000-0000

Experience

Current Place of Employment *

Education *

Languages spoken (other than English)

Gender *

Female

Male

(needed for the purpose of background checks)

Personal Pronouns

she/her/hers

he/him/his

they/them/theirs

other

(check any that apply to your identity)

Do you volunteer with other organizations? *

Yes

No

If so, where?

Finding your place with us

In fewer than 250 words, tell us about your applicable experience with young learners. If you have none, tell us about any experience you've had that will be valuable to our students. *

Employing your creative voice, tell us who you are in a way that no one else could. (100 words max, please.) *

Why did you select RAWK to fulfill your Service Learning Requirement? Aside from credit for your class, what do you hope to gain from engaging with RAWK and our students? *

In the interest of protecting the safety and well-being of our students, we need to ask:

Have you ever been convicted of or plead guilty to a crime? *

No

Yes

The Fine Print

Media Release

Yes

No

I permit Read and Write Kalamazoo to take photographs, audio, and video recording of myself for the explicit purpose of chronicling, promoting, and celebrating the RAWK program. I understand that any media taken of myself taken during RAWK programming will not be used by anyone not affiliated with Read and Write Kalamazoo.

A lot of words of great importance:
As a condition of volunteering, I give permission for Read and Write Kalamazoo (RAWK) to conduct a background check on me, which may include a review of sex offender registries, child abuse, and criminal activity records. I understand that, if appointed, my position is conditional upon the staff at RAWK receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability RAWK, the employees and volunteers thereof, or any person or organization that may provide such information. I hereby grant to RAWK, and its authorized agents, vendors, officers, directors, employees, licensees, affiliates, successors, and assigns the non-exclusive, irrevocable, perpetual, world-wide right and license to use, reproduce, display, perform, edit, create derivative works of, and distribute, in whole or in part, any photographs and/or recordings taken by or of me during activities sponsored by RAWK, for any purpose, in any and all manner or media now known or hereinafter developed. By signing below, I acknowledge that I also understand that RAWK appreciates me and my enthusiasm, but I also acknowledge that RAWK is not obligated to appoint me to a volunteer position.

Please enter your initials to indicate you agree to the above terms. *