GIRL SCOUTS OF NORTHERN NEW JERSEY
This Application form must be returned only by mailing in the envelope provided to:
Paramus Service Center, Volunteer Development Department,
300 Forest Avenue,
Paramus, NJ 07652
Attention: Charisse Taylor, Chief Program Officer
APPLICATION FOR VOLUNTEER POSITION IN GIRL SCOUTING
First Middle _________________Last_________________Maiden__________________
Date of Birth_________________ Social Security________ ___ ___________Race/Sex__________/_______
Home Phone # Business #
E-Mail Cell Phone #
Service Unit Troop #
Street City Zip
Membership in other organizations:
Present Occupation: Employer:
Phone: Prior Employer:
Education or Special Training: □ high school □ college □ advanced degree □ other What field?
I am available to help: □ weekends □ evenings □ weekdays
I can help: □ once a year with a special workshop/event □ occasionally (2or 3 times a year) □ monthly □
PLEASE INDICATE THE AREAS IN WHICH YOU ARE INTERESTED:
□ becoming a troop leader/ □ working with individual girls as a □ helping fund development with
becoming an assistant leader mentor special events
□ working with a group of girls as a □ organizing events □ assisting public relations with local
□ working with adult committee □ helping with occasional office work □ other
My special interests, skills, or career I would like to share are:
Have you ever been a Girl Scout leader or held similar youth related positions?
IF INTERESTED IN WORKING WITH CHILDREN:
Age/Girl Scout level you prefer to work with (check one) □ K-grade 1 (Daisy) □ grade 2-3 (Brownie) □ grade 9-10 (Senior)
□ grade 4-5 (Junior) □ grade 6-8 (Cadette) □ grade 11-12 (Ambassador)
Indicate your experience with children:
Preferred location for troop meeting:
GSNNJ does not discriminate on the basis of military status, affectionate or sexual orientation, race, ancestry, nationality,
color, creed, religion, sex (including pregnancy), age, disability, national origin, citizenship, marital or familial status,
atypical hereditary cellular or blood trait, genetic information, mental or physical disability, perceived disability or AIDS or
History of Legal Involvement (A yes answer will not necessarily preclude appointment)
1. Have you ever been convicted of a criminal offense? Yes No
2. Have you ever been convicted of child abuse/neglect? Yes No
3. Is your driver’s license suspended or revoked? Yes No
4. Other than the above matters, is there any fact or circumstances involving you or your background that would call into
question your being entrusted with the supervision, guidance, and care of young people?
If yes, please explain on a separate page.
To transport girls, you must carry a minimum insurance of $100,000/$300,000, operate a registered vehicle, and have a valid
1. Will you transport girls in your vehicle? (Check one box)? □ No □ Yes (If yes, complete rest of this section.)
2. If you own a car, is it registered and insured? □ No □ Yes
Driver’s License #: State:
Car insurance company:
Amount of insurance carried: $ (per person/per accident)
CRIMINAL BACKGROUND CHECK AUTHORIZATION FOR VOLUNTEERS.
AGREEMENT (Please read the following carefully before SIGNING and DATING application.)
I, the undersigned, agree that:
The persons and organizations named in this application may be contacted. I hereby release and agree to hold harmless from
liability any person or organization that provides information concerning me to the Girl Scouts of Northern New Jersey. The
information I have provided herein is true and correct. Significant omission(s) or misrepresentations(s) of any information may be
considered justification for non-appointment or dismissal. If appointed as a volunteer, I agree to abide by the policies, standards
and procedures of Girl Scouts of the USA and the Girl Scouts of Northern New Jersey, and to fulfill my volunteer responsibilities to
the best of my ability. I hereby grant consent to the council to secure a criminal background check in accordance with New Jersey
PL 1994, Chapter 60.
Criminal Background Check (CBC):
I have applied for Volunteer Service with Girl Scouts of Northern New Jersey (GSNNJ) with my application for Volunteer Service,
IntelliCorp Records Inc., their agents, assigns or any other authorized third parties (collectively the “Investigators”) may be
performing, requesting, obtaining or conducting a background check on me. This background check may include and inquiry into
my Employment History, Education, General Character or Reputation, Work Experience, Volunteer Experience, Driving, and/or
Criminal History (collectively the “Information.)
I understand that GSNNJ may rely on any part or all of the Information in determining whether to extend and offer of Volunteer
Service to me. I further understand that if GSNNJ chooses not to extend an offer of Volunteer Service to me based upon the
information, I will be provided a copy of such information along with a summary of my rights under the Fair Credit Reporting Act.
I understand the background check is being performed by Investigators as part of the process to evaluate me prior to Volunteer
Service and is not conducted for any purpose other than in connection with my Application for Volunteer Service.
I have read this Pre-Volunteer Service Disclosure and by signing below hereby authorize Investigators to conduct a background
check as described here in conjunction with my application for Volunteer Service. I hereby release any and all Investigators and
GSNNJ from any and liability related to the procurement of disclosure of any information provided by me or obtained about me in
connection with my Application with GSNNJ. I further direct and authorize Investigators to conduct the background check and
further authorize any third parties who may be the custodians of or in possession of the requested Information to disclose such
Information to Investigators in connection with this background check.
Although furnishing your Social Security Number is not optional, it shall be used for NO other purpose than to make the process for
conducting a background search more accurate. It shall not be sold or in any way transferred to a third party except for the express
purpose of conducting the background check.
Note : Refusal to grant permission voids this application.
Signature of Applicant: Date:
Girl Scouts do not discriminate on the basis of age, disability, race, color, ethnicity, sex, creed, national origin, or socio-economic
All information on the Volunteer Application and references will be kept strictly confidential at GSNNJ Council.
Please return within 3 days.
For Council Use Only: Date received Received by:
GSNNJ Forms\Application for Volunteer Position in GS.doc 7/1/2010