PittServes Creative Empowerment for Youth Application

Your Name (first and last name)*

Your Pitt Email*

Phone Number*

Current Address*

Permanent Address*

Academic Year*
---FreshmanSophomoreJuniorSenior

Major

Gender

Date of Birth*

Race

Do you have any artistic abilities and/or interest?*
YesNo

If yes, what are they?

Have you ever worked with children?*
YesNo

What steps would you take to engage a hesitant student in an arts-based project?

Please list any organizations you have worked with as a volunteer.

Please include the organization name and contact information, as well as the name of your direct supervisor, dates of involvement, and reason for leaving.

I consent to and understand that:

1)The references and youth serving-organization I listed may be contacted by mail, telephone, email, or in-person;

2)The information I provided may be used to conduct a background check, to include a search of public domain records, driving records check, juvenile and adult criminal history check, military records, and other records where required by local, state, or federal law for volunteers working with youth; (original copies of the clearances may be given to the volunteer once copies are made and an employee verifies with his/her signature that he/she has seen the original);

3)I am required to attend Creative Empowerment for Youth trainings, including monthly Saturday trainings;

4) I am responsible for engaging my student(s) in 2 to 3 art projects during my time as a volunteer, attending each weekly session unless there is an approved absence, and creating a weekly lesson plan;

Please read the following carefully before signing this application:

I understand that this is an application for a volunteer opportunity and is an unpaid position.

I certify that all information I have provided or will provide to Creative Empowerment for Youth, including this application, is true, correct and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would affect my application for a volunteer position. I understand that information contained on my application will be verified. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant or my termination as a volunteer.

At any time while involved with the Creative Empowerment for Youth program, I agree to immediately inform my contact person of any and all infractions, violations, charges and convictions related to any civil, domestic, or criminal occurrences. I understand that Creative Empowerment for Youth program coordinator, student leaders, and team leaders need to be fully
informed to provide the best guidance or support possible.

Electronic Signature*

Date*