Adult Volunteer Application Form

ADULT VOLUNTEER APPLICATION

Name

Title

Date of Application

Gender

Date of Birth

Driver's License Number

State of Issue

Social Security Number

Cell Phone

Alternate Phone

Occupation

Home Address

Household Income

Is your child a participant with Special Reach?

Yes No

What is your current employment status?

Employed Self-Employed Unemployed Student

In the event we are in need of additional volunteers, can we contact you 24 hours before a program/event?

Yes No

Please list all languages you communicate with (i.e. Spanish, American Sign Language, etc.)

What is the name and address of your place of employment?
Type N/A if unemployed

Please list the dates that you are available to volunteer.

Email Preference

We would like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Electronic Newsletter‎ Recruitment Appeals‎

Emergency Contact Name

Copy of Cell Phone

Alternate Phone

Relationship

Email Address

Consent for Criminal Background History

I hereby authorize Special Reach Inc. and/or its agents to make an independent investigation of my background, references, character, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment or volunteer service now and, if applicable, during the tenure of my employment/volunteer service with Special Reach Inc. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication and delinquent conduct committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee/volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by Special Reach Inc., and that a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do for myself, my heirs, executors and administrators, hereby release and forever discharge and agree to indemnify Special Reach Inc., and each of their officers, directors, employees, and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims, and demands whatsoever (including claims for the negligence, gross negligence, and/or strict liability of Special Reach Inc.), and any and all related attorney’s fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member. The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Name

By signing, I agree to the above information.

Clear

Confidentiality Agreement

As a Special Reach volunteer I agree to follow the confidentiality guidelines listed below: 1) I will not ask any client, child or family questions of a personal nature that are not necessary to being a helpful volunteer. 2) I agree that client families have a right to keep all health and/or medical information confidential. 3) I understand that all personal information about the client families is private and confidential. I will not discuss this information with anyone other than appropriate Special Reach staff members, except: a)as mandated by law; b)to prevent a clear and immediate danger to a person or persons; c) where I am compelled to do so by a court or pursuant to the rules of a court. 4) I understand that following these guidelines is important so that the client family members are able to trust me as a volunteer. 5) If I become aware of any situation that is (or may become) unsafe for someone I am working with, I will discuss it with the Special Reach staff immediately. 6) I understand that failure to keep personal information confidential will lead to termination of my volunteer position with Special Reach.

By signing, I agree to the above information.

Clear

Disability

Can you perform the job and with or without a reasonable accommodation. If an accommodation is needed, please let us know.

Please respond in the box provided:

Statement of Understanding & Waiver of Liability

I understand and agree: 1)That I must complete an application form to formally apply for a volunteer the position with Special Reach. 2) That I will be screened to determine eligibility to volunteer with children. I hereby give my consent to such screening. 3) That in order to be accepted as a volunteer, I must never have been convicted of child abuse or neglect, assault or sexual assault, or any other crime(s) against a person. 4) That should I be unable to volunteer as scheduled, I will notify the staff at Special Reach prior to my absence. 5) That any information known about client families is confidential and I am not allowed to discuss such information with anyone other than the assigned Special Reach staff. 6) That I will report any suspicion of abuse or neglect to Special Reach Staff immediately to make a report to the Texas Department of Family Protective Services (DFPS) at 1-800-252-5400. 7) That as a volunteer I will not be covered for personal injury or personal liability through Special Reach, Inc. 8) That Special Reach, Inc. and it’s employees will not be held responsible or liable by me in any way whatsoever as a result of any incident which might be construed to adversely affect me or my health, safety or welfare. 9) That I knowingly waive all rights to hold Special Reach, Inc., or the family of the child to whom I am assigned, liable as a result of any incident. 10) That I have fully disclosed to the Special Reach Staff, information about my physical and mental health which might affect my performance as a volunteer, and I acknowledge full responsibility for any consequences of my failure to disclose that information. 11) To follow all procedures, policies and practices established by Special Reach, Inc., while serving as a volunteer. *That by my online authorization, I hereby give my consent to be photographed and/or interviewed by Special Reach Staff for the purpose of education and/or publicity. This consent is expressly intended to release from liability all personnel of Special Reach, Inc. I have read, and understand each of the above statements. I hereby voluntarily and knowingly agree to the terms contained herein, and will comply with these statements as written.

By signing, I agree to the above information.

Clear

I Agree

I understand and agree that submitting this application form does not automatically register me as a Special Reach volunteer, and that there may be certain qualifications I must meet, including acceptance of established volunteer policies and procedures before I may begin volunteering. By submitting this form, I attest that the information I have provided on the form is true and accurate.

Agree