Teen Volunteer Application Form

TEEN VOLUNTEER APPLICATION FORM

Name

Date of Application

Date of Birth

Age

Cell Phone

Gender

Home Phone

Email

Home Address

Household Income

Name of School and School District

Grade Level

School Phone

Parent's Name

Parent's Cell Phone

Parent's Home Phone

Parent's Email

Parent's Place of Work

Parent's work Phone

Please list the dates that you are available to volunteer.

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.)

Notes:

Medical Permission: In the event that I cannot be reached to authorize medical attention for my child, I authorize a representative of Special Reach to seek medical attention and grant medical staff permission to treat my child. I will not hold Special Reach staff liable for any accidental injury incurred by my child during The Special Reach program hours.

Parent signature

Clear

Date

Photo Release: I give permission for photographs or video of my child to be used by Special Reach Inc. to portray and/or promote Special Reach activities. In no way will my child be exploited by the use of such photographs or videos.

Volunteer signature

Clear

Date

Parent signature

Clear

Date

Emergency Contact: Two alternate contacts - we need two people other than yourself to contact in case we can't reach you in the event of an emergency. We prefer that these people have contact numbers different than your own.

Name

Address

Cell Phone

Home Phone

Work Phone

Relationship to Teen

Name

Address

Cell Phone

Home Phone

Work Phone

Relationship to Teen

I understand that as a Special Reach teen volunteer, that I will conduct myself in a manner that is consistent with the mission of Special Reach Inc.

Volunteer signature

Clear

Date

I understand and agree:

1) That I must complete an application form to formally apply for a volunteer position with Special Reach. 2) 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. 3) That should I be unable to volunteer as scheduled, I will notify the staff at Special Reach prior to my absence. 4) 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. 5) 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. 6) That as a volunteer I will not be covered for personal injury or personal liability through Special Reach, Inc. 7) That Special Reach, Inc. and its 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. 8) 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. 9) 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. 10) To follow all procedures, policies and practices established by Special Reach of San Antonio, Inc., while serving as a volunteer. 11) 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 of San Antonio, Inc. 12) I understand that failure to keep personal information confidential will lead to termination of my volunteer position with Special Reach. 13) 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 Teen signature.

Clear

By signing, I agree to the above information Parent signature.

Clear

Disability: Can you perform the job with or without a reasonable accommodation? If an accommodation is required, please let us know in the box provided.

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.

I agree

Agree