Application for Volunteer

Service in Girl Scouting

                  Employment Experience (list most recent first) Please
Last Name First Middle provide accurate and complete information for all employment
      (including temporary, part-time, self-employment and
Mailing Address unemployment for the past five years). Attach additional
sheets if necessary.
                 
City State Zip      
Please check the best way to be contacted: Organization Name
Day Phone (      )                  
Dates employed (to and from) Position
Evening Phone (      )      
           
Cell Phone (      )      
Supervisor’s Name Phone #
     
E-mail Address      
Organization Name
     
Social Security Number            
Dates employed (to and from) Position
     
Date of Birth            
Supervisor’s Name Phone #
     
Driver’s License Number 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.
Other states of residence in past five years
Attach additional sheets if necessary.
Are you 18 or over? Yes No
Are you currently a member of Girl Scouts? Yes No      
Organization Name
What type of volunteer service interests you?
Advisor/Leader Office/clerical work            
Other support to girls Training adults Dates of Volunteer Service (to and from) Position
Fund-raising Outdoor program            
Marketing Activity/Program presenter Organization Contact Person Phone #
Computer/Website Community organization
     
Public Relations/public speaking
Organization Name
Occasional opportunities to work with girls
Organizing Special Events            
Other       Dates Volunteer Service (to and from) Position
Which volunteer pathway is preferred?            
troop events camp series travel virtual Organization Contact Person Phone #
List any specialized skills:       How did you learn about Girl Scout volunteer opportunities?
Language skills other than English:       School Brochure Girl Scout volunteer
Employer Media Girl Scout staff
Why are you interested in a Girl Scout volunteer position?
Website Other__________________________
     
Educational Background
Grade groups preferred (if relevant to position)
Educational Institution:      
Grades K - 1 Grades 2 - 3 Grades 4 - 5
Grades 6 - 8 Grades 9 - 10 Grades 11 - 12 Highest Year Completed:      
Adult Degree/Credits:      
Location, time available or other preferences: Educational Institution:      
      Highest Year Completed:      
School (if applicable)       Degree/Credits:      
Daughter’s Name (if applicable)       GED (General Equivalency Diploma)? Yes No
Other Training and Cert. Completed Date Expires 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
Please indicate any other names you have used that may be against an otherwise qualified individual on the basis of race,
necessary for us to verify the information on this application. 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
References law.
List three people (non-relatives) who are familiar with your
I hereby authorize you to check all of my educational,
qualifications for Girl Scout service:
personal and employment references. I further authorize
            these references to release to you information that they have
Name Relationship about me.
      I authorize the Girl Scouts Heart of the South to conduct a
Mailing Address criminal records check and agree that, if requested, I will fully
                  cooperate in providing all information and signing of
City State Zip documents necessary to conduct such a check.
      I understand that any misrepresentation, omission or
Day Phone Evening Phone falsification of any fact from this application or during any
      interview will be cause for rejection of this application or
E-mail Address dismissal from volunteer services. I also understand that
acceptance for volunteer services are subject to verification of
            references.
Name Relationship            
      Signature Date
Mailing Address Please return completed application via mail or fax to:
                 
City State Zip Girl Scouts Heart of the South Girl Scouts Heart of the South
Columbus Service Center 1007 Old Humboldt Road
            P. O. Box 2492 Jackson, Tennessee 38305
Day Phone Evening Phone Columbus, Mississippi 39704 F (731) 661-0011
      F (662) 328-1220
E-mail Address Attn:       Attn:      

            Girl Scouts Heart of the South Girl Scouts Heart of the South
Corinth Service Center Memphis Service Center
Name Relationship
P. O. Box 1145 P. O. Box 240246
      Corinth, Mississippi 38835 Memphis, Tennessee 38124
Mailing Address F (662) 286-8142 F (901) 797-2183
                  Attn:       Attn:      
City State Zip Girl Scouts Heart of the South
Girl Scouts Heart of the South
            Grenada Service Center Tupelo Service Center
Day Phone Evening Phone 2430 Sunset Drive, Ste. D P. O. Box 1087
Grenada, Mississippi 38901 Tupelo, Mississippi 38802
      F (662) 680-3164
F (662) 226-0258
E-mail Address
Attn:       Attn:      
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 For Office Use Only
offender)? A conviction will not necessarily bar your
Application reviewed by____________________________
acceptance as a volunteer. Yes No
Date___________________________________________
If yes please explain place, date and disposition of any
conviction:       Paid Membership ($12)_____________________________
ID Verified: Yes Date__________________________
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: www.girlscoutshs.org
 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       Date      

After the background check is completed, the information below will be destroyed.

Print your name here      

Driver’s License Number      

Social Security Number      

Date of Birth      

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: www.girlscoutshs.org