Criminal History Check Disclosure Notice and Release Authorization EXTENSION VOLUNTEER

Transcription

1

2

3 Office of Human Resources Criminal History Check Disclosure Notice and Release Authorization EXTENSION VOLUNTEER *Please attach a copy of your official photo ID with this completed release* FULL Legal Name (Last, First, Middle Name) New Volunteer Returning Volunteer Date of Birth (MM/DD/YYYY) Other Name(s) Used (maiden name, previous married name(s), aliases, assumed names, etc.) Current Mailing Address If you have not lived at your current address for the last seven (7) years, please complete the following. City State From To City State From To City State From To City State From To (Add another page if necessary) Primary Phone Number Alternate Phone Number Address Position Title Extension Volunteer NON driving Extension Volunteer - driving (please submit a non-employment driving history) OSU Extension Office: 4-H State Office - Mario Magaña Álvarez Program Name: 4-H Outreach YP Recheck M IT H L F PI A DISCLOSURE NOTICE AND AUTHORIZATION FOR BACKGROUND INVESTIGATION Oregon State University (the University ) may request, for lawful employment purposes, background information about you from a third party or agency in connection with your application for employment or volunteer service or if you are contracted to provide services to the University. The University may obtain background information, such as criminal history information pursuant to OAR 576, Division 055 et seq, credit reports pursuant to ORS 659A.885 (commonly known as credit history checks ), or other such related reports. A credit history check will only be conducted in narrow circumstances pursuant to statute. Additionally, the University may obtain education history, work history and reference information regarding your employment and performance from current and former employers and personal and professional references in the course of conducting recruitment and selection processes. The University or a law enforcement agency will prepare or assemble criminal reports, educational history, and other similar background reports for the University s use in conducting a background investigation. The types of information that may be obtained by the University in the course of verifying your background information may include, but are not limited to: address history; criminal records and history; public court records; driving records; accident history; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; and other information bearing on your character, general reputation and personal characteristics. The University will only conduct a criminal background check where the applicant has received separate notification that the position is of a critical or security-sensitive nature pursuant to OAR et seq. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews; and other information sources. Oregon State University is an affirmative action/equal opportunity employer. You may have rights under Title VII of the Civil Rights Act of If you wish to obtain further information, you must contact the Oregon Bureau of Labor and Industries. Page 1 of 2 11/13/2013

4 Office of Human Resources Criminal History Check Disclosure Notice and Release Authorization EXTENSION VOLUNTEER *Please attach a copy of your official photo ID with this completed release* Authorization for Background Investigation I have carefully read and understand this Disclosure and Authorization Form. By my agreement below, I consent to the University obtaining background information for purposes related to employment, volunteer service, or contracting for services. My consent includes preparation of background reports and related information by the University or a law enforcement agency and to the release of such background reports and related information to the University and its designated representatives and agents, for the purpose of assisting the University in making a determination as to my eligibility for employment, promotion, retention, volunteer service or for other lawful purposes related employment or contracting for services. I also authorize the University to obtain any reports or background information necessary to verify my identity and fitness for the position for which I am applying. I understand that refusal to consent to a background check or to release related background information will disqualify me from consideration. I understand that information contained in my employment, volunteer service application or service contract or otherwise disclosed by me before or during my employment or service, if any, may be used for the purpose of obtaining and evaluating background reports on me. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information regarding me that is requested by the University, the University s contracted reporting agency, or law enforcement agency either orally or in writing. I understand that personally identifiable information, such as date of birth, may be requested by the University or law enforcement agencies solely for the purpose of accurately verifying my identity. If there is a need to verify my identity or if I have lived outside the state of Oregon in the last seven (7) years, I understand that I may be asked by the University to submit my fingerprints or additional information as requested by the University. Failure to submit to fingerprinting or failure to provide additional information to verify my identity will cause me to be removed from further consideration. I understand that nothing herein may be construed by me as an offer of employment, appointment to a volunteer service position, or a contract for services by the University. I understand that further consideration by the University of my candidacy is contingent upon my consenting below and, therefore, I acknowledge that I authorize the University to obtain such reports and background information. I understand a copy of my Disclosure and Authorization for Background Investigation form will be maintained on file by the University in accordance with state rules and laws. I understand that I have the right to receive a copy of my background report from the Oregon State Police, Federal Bureau of Investigation, and records resources that have provided this information to the University. I also understand that before I am denied employment based, in whole or part, on information contained in the background report received from the reporting agency, I will be provided a copy of the report and a written copy of my rights under the Fair Credit Reporting Act: I understand that if I am going to dispute the accuracy of information in the report, I must notify the University within fourteen (14) calendar days of the date of the University s notification letter to me. I understand that appealing the University s decision or challenging information provided to the University by the reporting agency will not cause a delay or postponement of the University hiring process or employment decisions. I hereby release and discharge, to the extent permitted by law, Oregon State University, its employees, and any individual or agency obtaining information on the University s behalf, for any and all claims known or unknown, damages, losses, liabilities, cost, or other expenses arising from the retrieving, reporting, and disclosure of information in connection with this background investigation. I understand employees and volunteers whose position descriptions have been designated as critical or security sensitive are required to notify the Assistant Vice President or Associate Director of the Office of Human Resources if they are convicted of a crime relevant to determination of fitness as identified in OAR while serving in these positions. Incumbents in Youth Programs may have criminal history checks repeated every 24 months. By my signature below, I certify and affirm that I have read and understand the above Disclosure Notice and Authorization for Background Investigation form and am aware of how to access a summary of my rights under the Fair Credit Reporting Act. I certify that I have authorized the University or a law enforcement agency to conduct a background investigation about me as outlined herein. Applicant s Signature (actual signature vs. typed or electronic) Date Guardian s Signature (required for minor applicants) Please return completed aplications to: Urban League of Portland Workforce Department 10 N Russell Street Portland, OR **Criminal History Check Release Forms need to be turned in with applications in a sealed envelope** Page 2 of 2 11/13/2013

5 ULPDX Volunteer Liability and Confidentiality Agreement Any volunteer, intern, practicum student or any other person who is volunteering their time to the Urban League of Portland for no monetary compensation (as defined below), must understand and agree that confidential information is proprietary to the Urban League of Portland. This confidential information is intended for the volunteer s internal use only and shall be protected by the volunteer with the same diligence, care and caution that the volunteer uses to protect her / his own confidential information. Confidential information is defined as any trade secrets, confidential documentation, technical drawings and design, financial and donation data, pricing data, corporate decisions and plans, procedures, and any other information marked or designated by the Urban League of Portland as confidential or proprietary. Any public information (such as the Annual Report) is not considered confidential, unless determined confidential by the Urban League of Portland. Upon ending their volunteer position with the Urban League of Portland, the Volunteer shall return any and all confidential information as stated by the Urban League of Portland policy. Leaving the Volunteer position at Urban League of Portland does not end this confidentiality agreement and the volunteer is still bound by confidentiality. The Urban League of Portland and the volunteer must acknowledge and agree that it would be extremely difficult to measure the amount of damages from a breach or threatened breach of any confidential information. The Urban League of Portland and the volunteer also agree that money damages alone would be an inadequate remedy, and that in such an event, the Urban League of Portland shall be entitled to temporary and permanent injunctive relief to restrain a volunteer from any such breach or threatened breach. Volunteers must acknowledge and agree that fulfilling volunteer duties at any program site outside of Urban League of Portland s main location (10 N. Russell, Portland, OR 97227) or it s associated properties, including clients homes, transportation, and field activities will be carried out at the volunteer s own risk. The Volunteer agrees that they are volunteering upon their own initiative, risk, and responsibility. The volunteer also agrees that their executors, and administrators, to remise, release, and discharge the Urban League of Portland, its programs, its officers and employees from all claims, demands, actions, or causes of action, on account of any injury to the volunteer which may occur while involved in any activity as a volunteer at the Urban League of Portland program sites outside of the Urban League of Portland s main location. The volunteer agrees to indemnify the Urban League of Portland in case of any claim, lawsuit or similar arising out of the activities or actions conducted by the volunteer. Agreed to and signed this day of, 20. Print Name Signature Urban League of Portland Volunteer Application Page 3 of 5

6

7 . Urban League OF PORTLAND Empowering Communities. Changing Lives. Permission to Use Photograph I hereby grant the Urban League of Portland (the League ) permission to use my likeness in any photograph, video or other digital or print reproduction (the Materials ) with or without my name in any and all of its publications, including websites, without payment or any other consideration. I waive the right to inspect or approve the Materials and to receive any royalties or other compensation arising or related to the use of the Materials. I hereby hold harmless and release the League and its representatives from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I am 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release. Signature Date Printed Name If the person signing is under age 18, there must be consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person. Parent/Guardian s Signature Date Parent/Guardian s Printed Name Urban League of Portland 10 N. Russell Street Portland, OR /2/12

8 ULPDX Reference Authorization Form Volunteer Name: Date: Responses to Future Requests for Reference: Volunteers at ULPDX are asked to decide if they want to authorize the organization to release information to future employers, volunteer supervisors, or academic institutions in the form of references and letters of recommendation. Please complete this form, and sign either Option A or Option B. If you decide that you want to change the status of this form, you must do so before the completion of your volunteer service at ULPDX. If this form is not signed, then ULPDX will automatically use Option B in responding to all future requests for reference information. Option A I,, Voluntarily authorize all persons with and for whom I have worked at ULPDX to release to prospective employers, volunteer supervisors, and/or academic institutions any information regarding my volunteer service. This information may be given verbally or in writing it may include information regarding performance appraisals, work performance, and any other related information regarding my volunteer service. I release ULPDX and all persons with and for whom I have worked at ULPDX from any liability for any injury and damages that may result from furnishing to any person any information regarding my volunteer service with ULPDX. Option B I, Do not authorize ULPDX to provide detailed reference to information about me. I understand that all future calls regarding reference inquiries will be provided only with: My date of volunteer service My volunteer title Other titles I held at ULPDX I understand that ULPDX may provide future reference seekers with a copy of this form to indicate that ULPDX is providing this information at my request. I understand that ULPDX may provide future reference seekers with a copy of this form to indicate that ULPDX is providing this information at my request. Signature Date Signature Date Urban League of Portland Volunteer Application Page 4 of 5

9 Position Description for Volunteer Camp Counselor 4-H Middle School Diverse Summer Camp 2015 Position Title: 4-H Volunteer Camp Counselor Compensation: This is an unpaid volunteer position. Duration: August 10 th to August 15 th, 2015 Location: 4-H Campsite in Salem, OR. The Urban League of Portland will provide transportation to and from the campsite in Salem. Supervision: Reports to: Debra Lindsay, Urban League of Portland, Director of Workforce Development and supervised by: Byron Peterson, Urban League of Portland, Employment Training Instructor Purpose of Position: To serve as the leader, role model, and primary adult responsible for the children or youth in your group, and to assist 4-H faculty, staff, and volunteers in implementing the program (including chaperoning classes, physical activities, presentation, and events). Benefits of the Position: Fun interacting with younger youth; expand your knowledge; develop leadership skills; enhance your college application; meet other highly motivated young people and professionals; learn about scholarships, careers, and prepare for college; build a strong resume and earn lots of community service hours; receive strong letters of recommendation for college or scholarships. Major Duties: Serve as camp counselor, coach, role model and mentor, for 5-7 kids at all times. Ensure the health and safety of all participants during day and night. Assist 4-H faculty and staff with check-in and check-out at the 4-H Center. Assist instructors in classes, workshops, presentations and events. Be a dorm chaperone for your group at night and make sure they eat and sleep well. Participate in night Camp Counselor and Volunteer meetings, skits, plays, campfires, etc. Touch base with the Camp Director nightly or as needed. Other Duties: Serve as a positive role model for campers. Provide guidance and care to campers. Enforce rules and behavioral expectations including dress code. Help youth stay on task and respectful during classes and events. Help solve problems that the youth may experience. Report accidents, problems, and/or successes to both the nurse and Camp Director.

10 Qualification/requirements of the position: Must be either: 1) 18 years old or older 2) Aged 16 to 18 years old with previous camp counselor experience Complete a Camp Counselor s Application. Experience supervising groups of youth Comfortable in a multicultural environment. Excellent leadership skills. Pass a background check and drug screening. Willing to participate in physical activities, educational workshops, and talent shows. Have a positive attitude and a good sense of humor. Willing to help younger youth to have a positive camp experience. Willing to motivate youth to work hard, get good grades, and continue their education. Able to stay overnight during camp. Expenses: Lodging and meals are free for Camp Counselors. The Urban League will provide transportation to and from the camp in Salem. Volunteer Camp Counselors are eligible for a stipend of $250. All Application Materials Should be Submitted to The Urban League of Portland. If you have any questions or concerns please contact: Susan Johnson, Workforce Program Assistant at: (phone) ext. 620, ( ) sjohnson@ulpdx.org or Debra Lindsay, Director of Workforce Development at: (office) ext. 640, (cell) , ( ) dlindsay@ulpdx.org