Volunteer Application

Transcription

1 ECHO GLEN CHILDREN S CENTER Washington State Department of Social and Health Services Juvenile Rehabilitation Administration Volunteer Application SE 99 th Street, Snoqualmie, WA ) / 425)

2 VOLUNTEER APPLICATION NOTE TO THE APPLICANT: Please type or print responses. If additional space is needed for answers or comments, use reverse side. It is the policy of the Department of Social and Health Services to utilize and endorse a wide range of volunteer services. Involvement of carefully selected residents/individuals as volunteers enhances both the quality and quantity of services we can offer. Your willingness to be a part of our volunteer activities is appreciated. In order to ensure the safety of clients, staff, and members of the community, we may need to check Department of Licensing and Washington State patrol Records. NAME LAST FIRST MIDDLE BIRTHDATE SOCIAL SECURITY NUMBER RESIDENCE ADDRESS STREET APARTMENT NUMBER TELEPHONE NUMBER (INCLUDE AREA CODE) HOME: ( ) CITY STATE ZIP CODE MAILING ADDRESS, IF DIFFERENT FROM ABOVE WORK: ( ) EMPLOYER, IF APPLICABLE TELEPHONE NUMBER (INCLUDE AREA CODE) ( ) EMPLOYER ADDRESS STREET CITY STATE ZIP CODE POSITION SUPERVISOR HIGHEST EDUCATION LEVEL SCHOOLS ATTENDED LIST SKILLS, INTERESTS, AND HOBBIES WHY ARE YOU INTERESTED IN VOLUNTEERING? LIST YOUR GOALS AND OBJECTIVES. WHAT TYPES OF VOLUNTEER ROLES MOST INTEREST YOU? WHAT LANGUAGES DO YOU SPEAK OTHER THAN ENGLISH? WHERE DID YOU LEARN ABOUT THE DSHS VOLUNTEER PROGRAM? PREFERRED DAYS AND HOURS FOR VOLUNTEER SERVICE List previous volunteer experience on the back of this application. PERSONAL AND/OR PROFESSIONAL REFERENCES: NAME RELATIONSHIP TELEPHONE NUMBER (INCLUDE AREA CODE) ( ) EMPLOYER ADDRESS STREET CITY STATE ZIP CODE PERSONAL AND/OR PROFESSIONAL REFERENCES: NAME RELATIONSHIP TELEPHONE NUMBER (INCLUDE AREA CODE) ( ) EMPLOYER ADDRESS STREET CITY STATE ZIP CODE PERSONAL AND/OR PROFESSIONAL REFERENCES: NAME RELATIONSHIP TELEPHONE NUMBER (INCLUDE AREA CODE) ( ) EMPLOYER ADDRESS STREET CITY STATE ZIP CODE NAME The above information is true and correct. I do not object to necessary reference and records checks. DATE

3 VOLUNTEER ASSURANCE OF CONFIDENTIALITY ECHO GLEN CHILDREN S CENTER As a condition of my employment or service relationship with the Department of Social and Health Services, I commit and agree to be bound by the following: 1. I am bound by CFR 42 Part 2 Federal Confidentiality Regulations, governing Confidentiality of Patient Records. 2. I certify not to divulge, publish, mention, or otherwise make known to any unauthorized third party, orally or in writing, any information concerning a consumer receiving services from providers supported by or receiving benefit from the department, except when: a. I have an authorized consent for the release of such information from the consumer. b. I am required to do so by court order, federal or state laws and regulations in accordance with the federal regulations. 3. I will consult management for direction anytime I am unclear as to the interpretation of confidentiality regulations or the legality of requests made of me for information. 4. I agree to be bound by procedures for safeguarding consumer information, including: a. All patients identifying information will be kept out of sight when not in use. b. Discussions regarding patients will be held in places providing assurance of privacy. c. No patient identifying information, written, computerized or verbal, will be shared with other agencies, professionals, friends or family members without prior written authorization form the consumer. d. I will deny unauthorized requests for access to patient identifying information by anyone not employed by the Department of Social and Health Services, and refer such requests to my supervisor 5. I understand that the federal regulations set forth-specific penalties, which may be imposed. An unauthorized disclosure of patient identifying information or records may subject me to a fine of up to $500 for the first offense and up to $5000 for each subsequent offense. 6. I understand my Assurance of Confidentiality and these requirements do not cease at the time I terminate my relationship with the department. I agree to be permanently bound by this oath and by the regulations on confidentiality henceforth. VOLUNTEER SIGNATURE VOLUNTEER S PRINTED NAME DATE

4 NOTICE TO VOLUNTEERS VOLUNTEERS with unsupervised access to children, developmentally disabled persons and vulnerable adults need to have a background criminal check through the Washington State Patrol. This is necessary to implement Chapter 486, Washington Laws of 1987 as amended by Chapters 90 and 334 of Washington Laws of 1989 (RCW through ). DEPARTMENT OF SOCIAL & HEALTH SERVICES LEGISLATIVE & COMMUNITY REALTIONS For further information, contact your local Community Resource Program Manager.

5 Washington State Department of Social and Health Services Juvenile Rehabilitation Administration Echo Glen Children s Center To: From: Re: All Volunteers Patti Berntsen Associate Superintendent Reporting Requirement The 1998 Legislature established a requirement for all staff and volunteers working with youth to report any convictions that the may incur, while employed or in volunteer status with a state agency. Attached is a description of the legislative requirement, which outlines what crimes must be reported to Echo Glen, specifically felony sex offenses and/or violent crimes. Please review the attached form and sign and date on signature line at the bottom of the page. Your signature only indicates that you have been informed of this requirement. Please return the signed form to Echo Glen, to my attention if by mail, or you can drop it off at Reception during one of your scheduled visits. Thank you for your cooperation on this new requirement. If you have any questions, please feel free to contact me at ext

6 ATTACHMENT 4 Acknowledgement Form Reporting Criminal Conviction Attachment, Interim Directive, SSB /25/99 Acknowledgement of Additional Requirements to Report Criminal Convictions Persons who plead guilty to or are convicted of: a. any felony sex offense as defined in RCW 9.94A.030 and RCW 9A ; b. any crime specified in Chapter 9A.44 RCW when the victim was a juvenile in the custody of or under the jurisdiction of JRA; or c. any violent offense as defined in RCW 9.94A.030 are not allowed regular access* to juveniles within the JRA system. Any person who has entered a guilty plea or has been convicted of one or more of these offenses is not eligible for an employed, contracted, or volunteer position within JRA if that person will have regular access to juveniles within the JRA system. Current employees, volunteers, and contracted service providers who are authorized for regular access to a juvenile(s) must report any guilty plea or conviction of any of the above offenses. The report must be made to the person s supervisor within seven days of conviction. Failure to report within seven days constitutes misconduct under Title 50 RCW. Employees, volunteers, and contracted services providers who have reported a guilty plea or conviction for one or more of these offenses must not have regular access to juveniles within the JRA system. * Regular access means unsupervised access to a juvenile(s) for more than a nominal amount of time, that is the result of the person s regularly scheduled activities or work duties. For the purpose of this definition, juvenile means a juvenile offender under the jurisdiction of JRA or a youthful offender under the jurisdiction of the Department of Corrections who is placed in a JRA facility. I am aware of my additional responsibility to report any criminal convictions. (RCW and WAC , Background Checks; RCW , Sexual Misconduct by State Employees, contractors). Signature Date

7 PERSONNEL POLICY 532 Attachment B Juvenile Rehabilitation Administration Crimes Prohibiting "Regular Access" to Juveniles Violent Offenses (RCW 9.94A.030) *Arson 1; Arson 2; *Assault 1; Assault 2; *Assault of a Child 1; Assault of a Child 2; *Bail Jumping when charged w/ Murder 1 *Burglary 1; *Child Molestation 1; Drive-By Shooting; Extortion 1; Forgery when class A *Homicide By Abuse; *Homicide By Watercraft Indecent Liberties with Forcible Compulsion; *Kidnapping 1; Kidnapping 2; *Leading Organized Crime when class A; *Malicious Explosion of a Substance 1 & 2 *Malicious Placement of an Explosive 1 *Manslaughter 1; Manslaughter 2; *Murder 1 (incl. Aggravated Murder); *Murder 2; Possess an Explosive Device when class A *Rape of a Child 1; *Rape of a Child 2; *Rape 1; *Rape 2; *Robbery 1; Robbery 2; *Use of a machine gun in a felony offense; Vehicular Assault; *Vehicular Homicide Vehicular Homicide while under the influence of drugs or alcohol, or by the operation of a vehicle in a reckless manner; Any class A felony*; Any attempt to commit a class A felony, criminal solicitation of or criminal conspiracy to commit a class A felony; Any conviction for a felony offense in effect at any time prior to July 1, 1976, that is comparable to a felony classified as a violent offense under RCW 9.94A.030; and Any federal or out-of-state conviction for an offense that under the laws of this state would be a felony classified as a violent offense under RCW 9.94A.030. Felony Sex Offenses (RCW 9.94A.030, RCW 9A ) Child Molestation 1; Child Molestation 2; Child Molestation 3; Communication with a Minor for Immoral Purposes (if it is the second sex offense the person has committed); Dealing in Depictions of Minor Engaged in Sexually Explicit Conduct; Incest 1; Incest 2; Indecent Liberties; Failure to Register or Failure to Notify of Address Change, Transient Status, or Name Change (if original crime was a felony sex offense); Rape 1; Rape 2; Rape 3; Rape of a Child 1; Rape of a Child 2; Rape of a Child 3; Patronizing Juvenile Prostitute; Sending, Bringing into State Depictions of Minor Engaged in Sexually Explicit Conduct; Sexual Exploitation of a Minor; Sexual Misconduct with a Minor 1; Sexually Violating Human Remains; Custodial Sexual Misconduct 1; Voyeurism; Any felony with a judge's finding of sexual motivation; Any conviction for a felony offense in effect at any time prior to July 1, 1976, that is comparable to a felony classified as a sex offense under RCW 9.94A.030; Any felony that is an attempt to commit, criminal solicitation of, or criminal conspiracy to commit a sex offense; and Any federal or out-of-state conviction for an offense that under the laws of this state would be a felony classified as a sex offense. Other Automatic Disqualifying Crimes in RCW 9A.44 when the victim was in the custody or jurisdiction of JRA (non-felony crimes) Custodial Sexual Misconduct 2; Sexual Misconduct with a Minor 2; Sex Offender Failure to Register or Failure to Notify of Address Change, Transient Status, or Name Change (if original conviction was a non-felony sex offense) This list is based on the crimes listed in the RCW's as of the 2000 Legislative Session and is subject to change each legislative session.

8 INSTRUCTIONS FOR COMPLETING THE BACKGROUND AUTHORIZATION This form is to be completed by any contractor employee, volunteer, or student intern of the Juvenile Rehabilitation Administration (JRA) who will or may have unsupervised, or regular access to children, juveniles, or vulnerable adults. This form will be returned if any portion of the required information necessary to conduct a background check is not entered or is not legible. Failure to complete the authorization form will disqualify an employee or applicant from consideration for any covered position including their current covered position. SECTION 1: To be completed by the JRA hiring authority. 1. Required. An address label is preferred. 2. Required. 3. Required. 4. Required. 5. Required. SECTION 2: To be completed by the applicant (person to be checked). 6. Required. 7. Required. 8. Required. 9. Required. 10. Required. 11. Required. 12. Required. 13. Required. Must write NONE if none. 14. Required. Must include complete name at birth. If same as 9 through 11 above, must write SAME. 15. Required. Must list all married names used (male or female); must write NONE if none. 16. Required. Must list all nicknames used (male or female); must write NONE if none. 17. Required. 18. Required. 19. Required. 20. Required. 21. Required 22. Required. Must list driver s license number or state identification number; must write NONE if none. 23. Required. Indicate number of consecutive years and/or months lived in Washington State. 24. Read prior to moving to block Required signature of applicant or parent/guardian if applicant is under Required. The ACCESS Central Unit must receive the background authorization form within three (3) months from the date of the signature. SECTION 3: To be completed by JRA staff only. 27. List of authorized JRA staff maintained by ACCESS Unit. 28. Required. 29. Required. 30. Origination number (ORI) of institution, field office, or central office required. Upon completion, submit form to the Volunteer Coordinator as soon as possible for immediate processing.

9 JUVENILE REHABILTATION ADMINISTRATION USE ONLY (For use with Contractors, Volunteers, or Student Interns) BACKGROUND AUTHORIZATION Please print clearly using BLACK INK Green Hill School - ACCESS Unit Mail Stop: S21-5 Chehalis, WA (360) FAX (360) SECTION 1. AGENCY INFORMATION (COMPLETED BY AGENCY STAFF ONLY) Contractor Intern Volunteer 1. INSTITUTION/FIELD OFFICE NAME AND ADDRESS Echo Glen Children s Center SE 99 th St. [ MS: B17-41] Snoqualmie, WA TELEPHONE NUMBER (INCLUDE AREA CODE) 206) or 425) NAME OF CONTRACTING AGENCY 3. NAME OF JRA CONTRACT MONITOR Patti Berntsen 5. FAX NUMBER (INCLUDE AREA CODE) 425) SECTION 2. ALL QUESTIONS IN THIS SECTION MUST BE COMPLETED BY THE APPLICANT (PERSON TO BE CHECKED) 6. SOCIAL SECURITY NUMBER 7. DATE OF BIRTH 8. GENDER 9. RACE 10. Eye Color Male Female CURRENT NAME OTHER NAMES YOU HAVE BEEN KNOWN BY 11. LAST NAME 14. BIRTH NAME: LAST FIRST MIDDLE 12. FIRST NAME 15. OTHER MARRIED NAME(S) (WRITE NONE IF NONE) 13. MIDDLE NAME 16. NICKNAME(S)/OTHER NAME(S) (WRITE NONE IF NONE) 17. Have you been convicted of, or do you have charges pending for any crime?... If yes, give the crime, the conviction date or charge status, and the state where it occurred. YES NO 18. Have you been released from prison in the last seven years? If yes, give date of release. If yes, are you currently on active supervision? 19. Have you ever been found to have sexually abused, physically abused, neglected, abandoned, or exploited, a child or adult?... If yes, give name of court, state licensing board, disciplinary board, or dependency action, details of the finding, and state where it occurred: 20. Have you ever had a contract and/or license to care for children or adults denied, terminated, revoked, or suspended?... If yes, give date, contract and/or license type, name of contracting and/or licensing agency, and state where it occurred: 21. Has a court ever issued an order of protection against you for abuse, neglect, financial exploitation, or abandonment?... If yes, give date, court, and state where it occurred: 22. DRIVER'S LICENSE OR STATE IDENTIFICATION NUMBER 23. PRESENT NUMBER OF CONSECUTIVE YEARS LIVED IN WASHINGTON STATE Years: Months: 24. I understand that I am signing this statement under penalty of perjury. The above statements are true and complete to the best of my knowledge. I understand that any untruthful or purposefully misleading answer or any deliberate omission will result in my immediate disqualification as a provider, caretaker, licensee, contractor, and/or as an individual authorized to care for vulnerable adults or children. I hereby authorize JRA to obtain background information including but not limited to, convictions, licensing, child and adult protective services, and professional licensing records, from any law enforcement, any state and federal agency including other states and the FBI. JRA is hereby authorized to release the result of this and any JRA prior background check information to the agency, facility, entity, or individual named above. 25. SIGNATURE OF PERSON TO HAVE BACKGROUND CHECK OR PARENT/GUARDIAN 26. DATE (DATE SIGNED MUST NOT BE OLDER THAN THREE MONTHS) SECTION 3: To be completed by JRA staff and submitted to ACCESS Unit. 27. As a duly authorized and listed agent of JRA, I request that a background inquiry be conducted on the person named in Section DATE 30. ORI # 28. SIGNATURE Patti Berntsen

10 ECHO GLEN CHILDREN S CENTER RECREATION FACILITY VOLUNTEER RELEASE OF LIABILITY I,, understand that Echo Glen Children s Center, Department of Social and Health Services and the State of Washington assume no responsibility for my safety or for any accident or injury received while I am using the gymnasium or swimming pool for recreational purposes during non-working hours. I, therefore, assume full responsibility for any accident or injury to myself or my property while using the swimming pool or gymnasium for recreational purposes; and I release Echo Glen Children s Center, Department of Social and Health Services, and the State of Washington from any responsibility. I also agree to be responsible for the care of all equipment within the recreation area and to abide by all the posted rules and regulations governing these activities. Signature Date VOLUNTEER Title Unit To be filed at Reception

11 To: From: Subject: VOLUNTEERS Lori Parker Business Manager MEDICAL EMERGENCIES To assist us in cases of medical emergency, please indicate the name of your doctor, his/her address and telephone number, etc. on the lines provided. Volunteer Name Name of Doctor ( ) Doctor s Telephone Number Hospital Preference Do you have any chronic illness that could require medical care? Yes No If yes, please describe: Please list other person to contact in case of emergency. (spouse, father, mother, etc.) Name Address Telephone Number I authorize Echo Glen to provide emergency medical treatment, if necessary. Yes No Signature Date To be filed at the Health Center