Lake County Council on Aging Volunteer Application

Transcription

1 GENERAL INFORMATION Lake County Council on Aging Volunteer Application Name: (last) (middle) (first) Address: (street) (city, state) (zip) Telephone: (day) (evening) Volunteer Position: (Meals on Wheels, Grocery Shopper, Friendly Visitor, etc.) Location/Site: (East Ave, Madison, Eastlake, Pville/Fport, Kirtland, Wickliffe, Mentor) Do any physical/mental conditions exist that would prevent you from fully performing the duties described in the volunteer position description in which you are applying? No Yes (if yes, please explain): Where did you learn about the Lake County Council on Aging and our volunteer opportunities? EMPLOYMENT HISTORY Company Name: Dates Employed: Location: Position Title: EDUCATIONAL BACKGROUND High School: College: Highest Grade Completed:

2 ADDITIONAL INFORMATION Do you have experience working with senior citizens? No Yes If yes, briefly explain: Do you have homeowner s or renter s insurance? No Yes Name of insurance company: Do you have bodily injury liability insurance on your automobile? No Yes Name of insurance company: Have you ever been convicted of a crime? No Yes If yes, explain: Have you been convicted of a traffic violation in the last 3 years? No Yes If yes, explain: PERMISSION TO PERFORM BACKGROUND CHECK I hereby allow Lake County Council on Aging to perform a check of my background, including: Criminal record Driving record Past employment/volunteer history Finances Educational/professional status Personal references Physician or therapist and other persons or sources as appropriate for the volunteer jobs in which I have expressed an interest. I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for some types of volunteer work. I understand that information collected during this background check will be limited to that appropriate to determining my suitability for particular types of volunteer work and that all such information collected during the check will be kept confidential. I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability of the described volunteer work and such other information as they deem appropriate. I hereby certify that the above information is true, accurate, and complete, and that it may be shared with staff on the Lake County Council on Aging. (Signature) (Date)

3 Lake County Council on Aging Reference Request and Emergency Contacts Please list three references who have known you for at least two years. Please do not include relatives. Name: Address: Phone: City: Zip: Name: Address: Phone: City: Zip: Name: Address: Phone: City: Zip: EMERGENCY CONTACTS Name: Phone: Name: Phone:

4 DISCLOSURE UNDER FAIR CREDIT REPORTING ACT CONSENT TO PROCUREMENT OF CONSUMER REPORT FOR VOLUNTEERING PURPOSES Funding for the Lake County Council on Aging requires the agency to obtain a Motor Vehicle Report on all new volunteers for proof of a valid driver s license. The use of Motor Vehicles Reports for other than insurance underwriting (i.e. volunteering) falls under the Fair Credit Reporting Act. Therefore, this form must be completed by all applicants prior to our request for an MVR. The undersign hereby authorizes the Lake County Council on Aging, or its insurance agency, James B. Oswald Company, or its assigns, to obtain copies of consumer reports, including a Motor Vehicle Report, pertaining to me for volunteering purposes, and for use in rating and/or underwriting insurance for which the abovenamed agency may apply, and any renewal thereof. I understand that in obtaining such consumer reports, a consumer reporting agency may be used, and I do hereby authorize such use. I understand that in connection with my volunteer role with Lake County Council on Aging, I may be required to drive. Therefore, I understand that I must, at all times, carry a valid State of Ohio drivers license, carry current auto insurance that meets the minimum requirements for Ohio s Financial Responsibility Act and have no more than six (6) points on my driving record. Failure to comply with the above may result in termination of my volunteer position. I further agree and authorize Lake County Council on Aging to take whatever steps it deems necessary, at is sole discretion, to verify that I have a current and valid drivers license, that I carry auto insurance that meets the minimum state requirements and that I have no more than six (6) points on my driving record. This authorization includes Lake County Council on Aging conducting a search of my driver s license and driving history. Print Name: Signature: Driver s License No. State: Date of Birth:

5 PHOTO RELEASE I hereby assign to the Lake County Council on Aging all rights to use this photo of me and hereby authorize the reproductions of said photo by the Lake County Council on Aging without limitation. I indemnify and hold harmless the Lake County Council on Aging against any claims, including but not limited to, any claims in the nature of libel, slander, invasion of privacy or publicity rights and errors of omission. Signature: Date: AGENCY - VOLUNTEER AGREEMENT The Lake County Council on Aging agrees to provide adequate information, training, and supervision to each volunteer. We will be receptive to any comments from volunteers regarding the ways in which we might mutually better accomplish our respective tasks. We will treat volunteers as an equal partner with agency staff, jointly responsible for the completion of our agency mission. I agree to serve as a volunteer to the Lake County Council on Aging and to perform my duties based on my position description, the eligibility standards and policies, and to the best of my abilities. I agree to adhere to the agency rules, procedures, record keeping requirements, and confidentiality of the agency and client information. I will meet time and duty commitments or provide adequate notice so that alternate arrangements can be made. Signature: Date: WEB CHECK WAIVER I hereby certify that I have given agency (BGL192 Lake County Council on Aging) permission to obtain all criminal history information pertaining to me in the files of the Ohio Bureau of Criminal Identification and Investigation (BCI&I). By placing my fingerprint images on the WEBCHECK scanner, I am authorizing BCI&I to release criminal history information about me to the person(s)/agencies identified in this request for a period of one year from the date of this transaction. I hereby release BCI&I and any and all individuals identified in this request from all liability in connection with the dissemination of such criminal history information. Signature: Date: *Acceptance as a volunteer does not guarantee being hired into paid employment should a position become available. VOL:001 ( )

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