VOLUNTEER ENROLLMENT FORM

Transcription

1 433 Houston St. Manhattan, KS (785) (877) (Toll Free) (785) (Fax) Lori Bishop, Executive Director VOLUNTEER ENROLLMENT FORM VOLUNTEER INFORMATION Date of Birth: Name: Last First Middle Initial Female Male Address: City State Zip Phone Number : Cell Phone: Emergency Contact: Relationship (spouse, child, etc.): Phone # STATISTICAL/DEMOGRAGHIC INFORMATION Which ethnic group do you identify with? Caucasian African-American Pacific Islander Hispanic Asian Native American/Alaskan Native Other Previous/Current Employment: Availability: Check all that apply Ongoing Projects Weekends Mornings Afternoons Evenings One Day Events/Short Term Projects Are you a student: High School College Are you a person with a disability? If so, please let us know how we can accommodate or support your performance as a volunteer: I would like to receive the bi-monthly newsletter: By I would like to receive updates on new volunteer opportunities: By Postal Mail Yes No Are you a Veteran of the Armed Forces? Yes No MEDIA RELEASE AND PROMOTIONAL MATERIALS I give permission for Flint Hills Volunteer Center to use any pictures taken of me during volunteer work and/or video interviews for the purpose of promoting the program. Yes No REFERRED BY RSVP Volunteer Staff Other Community Agency Internet (Turn Over)

2 SAMPLE OF VOLUNTEER CATEGORIES - Check all that apply to you Healthy Futures Volunteer - Caring Callers Peer to Peer Transportation for Dr. Appt. Wellness Program Volunteer - KidZercise Advanced Bone Builders Leader Douglass Center - Hand-to-Hand Tutoring Summer Read Across America Summer Math Tutoring Schools of Hope Tutoring Program Jail Literacy Program Meal Delivery Riley Senior Service Center Ogden Community Center Habitat For Humanity - Habitat ReStore Building H4H Homes locally Recycling Food Pantry/Food Distribution Youth Volunteer Corps Thrift Store - Budget Shop Ogden Friendship House Blue Moon Thrift Shop Salvation Army American Red Cross - Bloodmobile Blood Drive Phone Call Reminders USO Center - Fort Riley - No Dough Dinners Cookie Brigade USO Staff Misc. Events Flint Hills Community Clinic Sunflower CASA Project Child Advocate Fort Riley American Red Cross Irwin Army Hospital Veterinarian Clinic Blood Drives Transportation and Insurance Statement - AGED 55 AND OVER ONLY Do you drive a car? Yes No Flint Hills Volunteer Center, Inc. (for RSVP volunteers) provides free volunteer excess accident and automobile liability insurance coverage while you are volunteering. This policy is secondary to your primary insurance. All volunteers agree to carry automobile liability insurance coverage equal to or greater than the minimum required by the state of Kansas. You can access further coverage details at RSVP Excess auto liability insurance requires the following: Drivers License #: Expiration Date: Life Insurance Beneficiary Information - AGED 55 AND OVER ONLY All RSVP members receive free life insurance in the event that something were to happen during your time volunteering. Who would you like to designate as your beneficiary? Name: Relationship: Phone: Address: City, State & Zip: Confidentiality Statement By signing below I acknowledge that I will abide by all the confidentiality guidelines set forth in the Flint Hills Volunteer Center, Inc. Volunteer Handbook. I WILL NOT: Discuss a volunteer or client in front of that person or any other individuals, volunteers or clients; Discuss a volunteer or client in front of other volunteers, visitors or staff not directly involved with that volunteer or client. Acknowledgement of Enrollment By signing below, I understand that I am not an employee of the Flint Hills Volunteer Center, the volunteer station, or the Federal Government and agree to serve without compensation. I also understand and agree to the terms and conditions set by Flint Hills Volunteer Center, Inc. Signature of Volunteer Date Signature of Volunteer Coordinator Date FOR RSVP OFFICE USE ONLY: Entered in system on Staff Initials:

3 Schools of Hope 433 Houston St. Manhattan, KS (785) (785) (Fax) Candice McIntosh, Program Coordinator TUTOR/MENTOR SELECTION FORM TUTOR/MENTOR NAME: TUTOR/MENTOR INTEREST/EXPERIENCE: Relevant Experience: Why did you choose to volunteer as a tutor/mentor? Describe attributes that will help you tutor (such as skills, experience, strengths in subjects, languages, etc.) PREFERENCES: requests will be filled on an availability basis LOCATION: Rate your top 3 site preferences from 1 being your most preferred and 3 being your least for placement Schools on the Westside Amanda Arnold Frank Bergman Marlatt Schools Close to Campus Lee Theodore Roosevelt Bluemont Over 10+ Miles of Travel Ogden Who would you feel most comfortable tutoring (in terms of age, gender, personality, etc.)?

4 PREFERENCES: requests will be filled on an availability basis SCHEDULE: Mark with an X the times you are available to tutor. *Students Include Class Schedule 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 Mon. Tues. Wed. Thurs. Staff Comments: FOR OFFICE USE ONLY: Staff Initials: Application Received On: Agreement Received On: KBI Background Check Completed On: Sex Offender Screening Completed On: Child Abuse and Neglect Registry Completed On:

5 AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION Flint Hills Volunteer Center s program, Schools of Hope believes that service to education merits the highest level of honesty, integrity and quality, and that education should be provided in a safe and nurturing environment with caring and responsible adults. Background Check Disclosure In order to qualify as a potential volunteer with SOH, all volunteers must pass a background check. SOH will obtain reports that detail any criminal history information for each volunteer applicant. Background check information will only be used to screen volunteers. This information is confidential will not be released to others. Failure to provide this information will result in the denial of any volunteer opportunities with SOH. Consent By signing this document, I hereby request and authorize the Kansas Bureau of Investigation and the National Sex Offenders Registry to furnish Schools of Hope and Flint Hills Volunteer Center with criminal history information as described in K.S.A.1985 Supp (b). This includes all information defined with K.A.R (b), (c), and (d). I voluntarily waive all right of recourse and release you from liability for compliance with this authorization. FULL NAME ANY OTHER NAMES USED CURRENT ADDRESS (STREET) (CITY) (STATE) (ZIP CODE) SEX RACE DOB ADDITIONAL INFORMATION DO YOU HAVE A CRIMINAL RECORD? IF YES, PLEASE DESCRIBE DATE SIGNATURE ======================================================================== RESPONSE (OFFICE USE ONLY):

6 State of Kansas Department for Children and Families Prevention and Protection Services Child Abuse and Neglect Central Registry 915 SW Harrison 5 th Fl. Room 530-East Topeka, Kansas Child Abuse and Neglect Central Registry Release of Information PPS 1011 REV 07/13 Page 1 of 1 I,, give permission for the release of any information concerning (Please print complete first, middle and last name) myself in the Child Abuse and Neglect Central Registry to: Contact Person: Agency Name: Mailing address: Phone Number ( ) I understand that all information released will be for the exclusive and confidential use of the above named organization/person/agency. I give permission for the release of any information concerning myself in the Child Abuse and Neglect Central Registry each year while I am employed or associated with the above agency. Yes No ** Please complete the information below by printing in ink. Please print legibly. Do not leave any space blank. All requested information is required to process this request. Incomplete information will result in the release not being processed and will be returned as insufficient.** First, Middle and Last Name: Maiden Name: (Female applicant only) Married Names, Nicknames or Other Names Used: (Use N/A if no other names used) Date of Birth: Race: Social Security # Gender: Male Female Signature: Date: Current Address: Each request must be submitted with payment prior to the request being processed. Please attach appropriate fee of $10.00 per release of information. All releases and fees should be sent via postal mail to the attention of DCF, Child Abuse and Neglect Central Registry, P.O. Box 2637, Topeka, KS The following state agencies are exempt from the $10.00 fee: JJA (Central Office or Facilities), KNI, Dept. Of Education- Central Office, KDHE, State Hospitals, State Correctional Institutions, Attorney General s Office, Kansas School for the Blind, Kansas School for the Deaf, Child Welfare agencies in other states. Subcontracting agencies are not exempt and will be assessed the $10.00 fee. Mentor record checks, i.e. Big Brothers Big Sisters, are exempt from the $10.00 fee. For a complete list of Mentor Programs, go to: If this is a mentor record check, please make sure the box below is checked. Mentor Program: If yes, please check FEE ATTACHED For Central Registry Use Only (This form supersedes CFS 1011 REV 7/11)