Urban Youth Impact: Volunteer Application

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Carefully read and answer all questions. Some of the requested information is necessary for background screening. (Date of birth and social security number will only be used for background screening purposes)

*Please notify Urban Youth Impact if any of the following information changes*

Personal Data



Add Apt. # On Second Line

Emergency Contact


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Health and Wellness

Background Information
According to Florida Law, depending on the volunteer position, volunteers having access to children must be background screened. We may check your driver's license record, civil litigation, criminal background, and credit history.

*Note: Conviction of a crime will not necessarily disqualify you for a volunteer position. Each conviction will be judged on its own merit with respect to time and job relatedness.

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Education Information

Skills, Talents, and Interests

Personal Contribution


Adult Volunteer Agreement

I understand that misconduct and/or repeated absenteeism without prior notification will result in an immediate dismissal from the program. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.

I permit Urban Youth Impact and any designates to photograph me, interview me, and/or make audio/video recordings of me. Urban Youth Impact may publish and disseminate the images for training, promotion, fundraising and other purposes via print, and/or electronic distribution via CD or web. I will not receive payment or any other compensation in connection with these images. I release Urban Youth Impact and its personnel from any and all liability which may or could arise from the taking, recording, publication, distribution or other use of these images.

I have read and understand the Volunteer Application. I agree to follow and comply with these guidelines. Should I have questions in regards to these guidelines, I know that the Volunteer Coordinator is available to answer any questions that I may have.

By participating as a volunteer I understand that I am making a commitment of service. My primary goal is to love, equip and empower the inner-youth and their parents for their God-given purpose. I will always put the children before myself. I will not intentionally do something that will jeopardize the safety of the children, staff or self.

I will not hold Urban Youth Impact of any other sponsoring or participating organization, church, or individual for any injury or illness that I incur from volunteering at Urban Youth Impact.