School on Wheels Volunteer Application
Personal Information
Name    First    Middle       Last
   Email
Application Date
   Gender Male    Female
   Address
 
     City       State       Zip Code
   Phone (999-999-9999) Home Work
Phone/Fax (999-999-9999) Mobile Fax
Preferred Contact Phone Home Work Mobile
Languages (conversational)
Talents/Skills (e.g. music, art)
   Emergency Contact Name    First       Last      Phone
   - Indicates a required field 
Education Information
   Select highest level completed   If "other", Explain:
   - Indicates a required field  
Employment Information
   Current Employer or School
Address
 
  City    State    Zip Code
Position   Years with Company 
 
References
List two references who have known you for at least one year and are not related to you. Please notify your references to expect our call. Reference #1 Name    First       Last       Relationship
Reference #1    Phone (999-999-9999)   Email 
 
Reference #2 Name    First       Last       Relationship
Reference #2    Phone(999-999-9999)   Email 
   - Indicates a required field  
School on Wheels Information
Indicate times you are available for tutoring. Please note most tutoring takes place after 3:00 PM Monday through Friday, except on weekends. Please leave fields blank for those days when you are not available. Monday From    To 
Tuesday From    To 
Wednesday From    To 
Thursday From    To 
Friday From    To 
Saturday From    To 
Sunday From    To 
 
Select grades (one or more) you prefer to tutor No Preference    K - 2nd    3rd - 5th    6th - 8th    High School
 
School on Wheels currently works in the following locations.Please indicate your geographic preferences.    Geographic preference #1 (select one)
 Area of Greatest Need: South Los Angeles
 Region 1: Downtown, Boyle Heights , Silverlake, Highland Park
 Region 2: South LA, Watts, Compton , Inglewood , Mid-City, Gardena, Lawndale, Hawthorne
 Region 3A: Currently Not Available
 Region 3B: San Fernando Valley, Simi Valley
 Region 3C: Glendale, Pasadena, Hollywood
 Region 3D: Ventura County
 Region 3E: Santa Barbara County
 Region 4: Long Beach, San Pedro, Norwalk, Whittier, Torrance
 Region 6: Currently Not Available
 Region 7: Orange County
Geographic preference #2 (select one)
 Area of Greatest Need: South Los Angeles
 Region 1: Downtown, Boyle Heights , Silverlake, Highland Park
 Region 2: South LA, Watts, Compton , Inglewood , Mid-City, Gardena, Lawndale, Hawthorne
 Region 3A: Currently Not Available
 Region 3B: San Fernando Valley, Simi Valley
 Region 3C: Glendale, Pasadena, Hollywood
 Region 3D: Ventura County
 Region 3E: Santa Barbara County
 Region 4: Long Beach, San Pedro, Norwalk, Whittier, Torrance
 Region 6: Currently Not Available
 Region 7: Orange County
 
Our program now includes Residential Foster Homes. Check this box if you are willing to work with a student living in a Residential Foster Home Residential Foster Home
 
How did you hear about School on Wheels?       If "other", explain:
   - Indicates a required field  
Background Security Information
To safeguard the children we serve, School on Wheels screens volunteer applicants. All information is confidential and will not be shared.    Yes  No I will provide School on Wheels with fingerprint and background check results.
   Yes  No Have you ever been convicted of a felony? If yes, please explain:
   Yes  No Have you ever commited any criminal offences against a minor?
   Date of Birth (m/d/yyyy)
Place of Birth    City    State       Country
   - Indicates a required field  
Statement of Understanding and Signature (required)
    If I am accepted as a Volunteer Tutor, I understand the need for consistency in meeting with my student on a regular basis and complying with School on Wheels' policies and reporting requirements.
THE ANSWERS I PROVIDED ARE TRUE AND COMPLETE, AND I AGREE TO THE ABOVE.


   Please type in your full name here.
 
What motivated you to volunteer with School on Wheels? Please share anything you would like us to know.
 
    
Version 2.0 (03/15/2009)