Vo lunteer Intake Application

Intake Date://* This information is for JPRN use only. Do not release this information to any third party without the owner’sconsent.日本の方は日本語でご記入ください。

Thank you for your interest in volunteer opportunities with JPRN. Please return thisform to: Japan Pacific Resou rce Network (JPRN), 310 8 th Street, Suite 305A,Oakland, CA 94607. When we receive your application, we will contact you andarrange an on-site interview when it's necessary.

Last Name:___________________ First Name/M.____________________
Street Address:__________________________________________________
City:_________________ State:_____ Zip code:___________________
Phone (Home):________________ Phone (Work):___________________
Email:_________________________ Date of Birth (yy/mm/dd)______________
Occupation (if student, school and major):______________________________
Languages: Primary _______________
Other ________________________

Secondary _______________

Emergency Contact
Person:_____________________________________________
Relationship: ______________________ Phone: _________________________How did yo u hear about JPR N?
______________________________________________________________________________________________________________________________________________________________________________________________________Why do you w ant to volunteer at JPRN?
______________________________________________________________________________________________________________________________________________________________________________________________________
Which positio ns interest you?
Translation/interpretation (Japanese-English, English-Japanese, Both)admin assistant duties

PR/marketing

project planning/Grantwriting

Fundraising

Japanese DTP

Japanese web design and update

Media editing (video, audio, online media)

Other IT(Program site visits escort (chaperon)

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Other assistance to the Japanese-speaking participants

What commitme nt c an yo u make?
Long-tern, ongoingcircle one:weeklybiweekly

Short-terncircle one:

one month

monthlya few weeks

a few times

Other (once)

What day (s) and time(s) are you available?
・SunMonTues・Morning (WedThu) Afternoon (FriSatFlexible) Evening () Flexible* Our regular working days are Monday through Friday. However, we might work on Sat. and Sun. when weimplement special programs.

How many hours/ per wee k do yo u like to volunteer? _____________
Do you have a criminal his tory?
NOYESExplanation
optio nal:____ _________________ _____________________________
Areas of special interest/abilitie s: _______________________________________________________________________________________________________________________________________________________________________
Describe other vo lunteer wor k y ou have do ne:__________________________________________________________________________________________________________________________________________________________
Describe what yo u liked or didn't like in past volunte er work:________________________________________________________________________________________________________________________________________
Describe your personal hobbies/ interes ts: ______________________________________________________________________________________________________________________________________________________________
Indicate any concerns you hav e (including health conditions)that mig ht affec t your ability to be an e ffective volunteer:____________________________________________________________________________________________________________________________________________________________________________________________________________
Additional Co mme nts: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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VOLUNTEER DECLAR ATION AND S TAT EMENT OFCONFIDENTIALITY
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE. I AGREE TO USE CONFIDENTIAL INFORMATIONONLY AS NEEDED TO PERFORM MY LEGITIMATE DUTIES AS VOLUNTEERRECEIVING INFORMATION FROM JAPAN PACIFIC RESOURCE NETWORK.
THIS MEANS, AMONG OTHER THINGS, THAT:A. I WILL ONLY ACCESS CONFIDENTIAL INFORMATION FOR WHICH IHAVE A NEED TO KNOW; ANDB. I WILL NOT IN ANY WAY DIVULGE, COPY, RELEASE, SELL, LOAN,REVIEW, ALTHER OR DESTROY ANY CONFIDENTIAL INFORMATIONEXCEPT AS PROPERLY AUTHORIZED BY JAPAN PACIFIC RESOURCENETWORK.
C. I WILL NOT MISUSE CONFIDENTIAL INFORMATION OR CARELESSYCARE FOR CONFIDENTIAL INFORMATION.
_______________________________________
Volunteer Signature___________________________
Date_______________________________________
Printed Name-----------------------------------------------------------------------------------------------PARENT/GUARDIAN LIABILI LTY WAIVER FOR MIORS(Must be completed if under age 18.)
I, the undersigned, as parent/legal guardian of ____________________________________
agree to waive Japan Pacific Resource Network and its staff from any and all liability
incurred in the performance of work for the agency. I agree to submit to the Agency inwriting any requests outlining limitations of work assignments prior to signing thisdeclaration.
_______________________________________
Signature of Parent/Guardian___________________________
Date_______________________________________
Printed Name___________________________
Relationship

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