Read Microsoft Word - Volunteer Application Special Olympics Northern California­ text version

SPECIAL OLYMPICS NORTHERN CALIFORNIA VOLUNTEER APPLICATION

Application Expires 3 Years Following Background Check Clearance

PROGRAM_________________________________________________________________ New Application Renewal PRINT FULL LEGAL NAME:_______________________________________________________________________________ First Name Middle Name Last Name DATE OF BIRTH:_____________/__________/_____________ Month Day Year MALE / FEMALE (Circle One)

E-MAIL ADDRESS:___________________________________________________FAX: (______)_______________________ HOME ADDRESS:________________________________________________________________________________________ Street City State Zip Code HOME TELEPHONE NUMBER: (______)_______________WORK TELEPHONE NUMBER: (______)__________________ Can you be called at work? Yes or No (Circle One) EMPLOYER/SCHOOL NAME: ________________________________ OCCUPATION: _______________________________ EMERGENCY CONTACT NAME: ___________________________________________________________________________ EMERGENCY TELEPHONE NUMBER: ( )

____Photo Identification Provided [checked by Special Olympics staff] ____ [initialed by Special Olympics staff]

(COMPLETE THIS SECTION IF UNDER AGE 18 YEARS OLD) PARENT OR GUARDIAN NAME: ____________________________________________________________________________ ADDRESS: _________________________________________________________________________________________________ Street City State Zip Code HOME PHONE NUMBER: (_____)__________________________ WORK PHONE NUMBER: (_____)___________________ EMPLOYER NAME: ___________________________________ OCCUPATION:__________________________________ SIGNATURE OF PARENT/GUARDIAN PROVIDING CONSENT TO PARTICIPATE:______________________________ Are you now or have you ever been involved with Special Olympics? Yes or No

If yes, what is/was your position? ____________________________________________________________________________ If yes, how many of year of service? __________________________________________________________________________ Do you have experience working with individuals with developmental disabilities? Yes or No If yes, please specify: _______________________________________________________________________________________ __________________________________________________________________________________________________________ GENERAL VOLUNTEER OPPORTUNITIES

I would like to volunteer in the following area(s): (Please refer to attached page for local volunteer opportunities.)

___ ___ Competitions Fundraising ___ ___ Aquatics *Coaching Office Support Basketball ___ ___ Bocce Ball Public Relations Medical (circle type of license) RN LPN EMT MD Bowling Track & Field Cross Country Skiing Powerlifting Volleyball Floor Hockey Golf

*If you checked Coaching, please check which sport(s) you are interested in: (Not every sport is offered in every area.)

Alpine Skiing Gymnastics Soccer Long Distance Running Snowboarding Long Distance Race Walking Snowshoeing Rollerskating Tennis

Softball

What special skills, licenses, or training do you have that would be valuable to Special Olympics Northern California? ___Red Cross ___Other Medical ___Clerical ___Photography ___Carpentry ___Computer ____Other Media/Graphics

Don't forget to complete the On-line Protective Behavior Training! www.specialolympics.org/protectivebehaviors

Revised 2/7/2008

SPECIAL OLYMPICS NORTHERN CALIFORNIA VOLUNTEER APPLICATION ­ PAGE 2 of 3 NAME: ____________________________________________________________ 1. 2. 3. 4. Do you use illegal drugs? Have you ever been convicted of a misdemeanor or felony offense? Have you ever been charged with neglect, abuse or assault? Has your driver's license ever been suspended or revoked in any state? Yes Yes Yes Yes Circle one or or or or No No No No

If you answered "yes" to any of the above questions, please provide a written explanation with this application. Answering yes to any of the above questions does not necessarily preclude you from participation as a volunteer. Please list any present/previous volunteer affiliations: Agency/Organization: _____________________________ Agency/Organization: _____________________________ 1. Contact: ___________________ Phone Number: (___)_________ Contact: ___________________ Phone Number: (___)_________

Please list two NON-FAMILY personal/professional references (minor must list one reference from school): Name: __________________________________________________________________________ Complete Address: ________________________________________________________________ Home Phone Number: (_____)___________________ 2. Work Phone Number: (_____)_____________________ Name: ___________________________________________________________________________ Complete Address: _________________________________________________________________ Home Phone Number: ( ) Work Phone Number: ( )

PLEASE READ THE FOLLOWING PROVISIONS BEFORE SIGNING THIS APPLICATION: I, as an adult age 18 or older [or as the parent/guardian of a minor volunteer applicant], understand and agree that: · the information I have provided may be verified and I hereby give permission to Special Olympics Northern California, Inc. ("SONC") to make inquiry of others concerning my suitability to act as a SONC volunteer. If I am an adult, I understand this verification and inquiry may include my motor vehicle operation history (DMV) and criminal background check(s). Further, I hereby release all parties and persons from any and all liability for any damages, and voluntarily waive any and all rights, claims, charges, complaints, or causes of action I have or may have against SONC, including its directors, officers, employees, and representatives, and any consumer reporting agency SONC may engage, as a result of SONC's and/or its representative's actions in seeking, using, and/or disclosing information gained from a Consumer Report or Investigative Consumer Report about me, or any other background check or report about me, including but not limited to information gained from the state or federal Sexual Offender Identification Line/Registry or any other source; in the course of volunteering for SONC I may be dealing with confidential information and I agree to keep said information in the strictest confidence; the relationship between SONC and volunteers is an "at will" arrangement, and it may be terminated at any time without cause by either the volunteer or SONC; I must have and maintain at least the minimum amount of automobile insurance as required by the State of California. I agree to notify SONC if I do not have such coverage if at any time I am asked to use my personal or any non-owned vehicle for SONC related business or activities. Furthermore, I agree to not allow any person who does not have automobile insurance and SONC's authorization to drive my vehicle for SONC related business or activities; I hereby grant SONC permission to use my likeness, voice, and words in or on television, radio, film, and SONC's Website(s), or in any other form, format, or media, to promote the activities of or fundraising for SONC; and I am responsible for informing SONC of ANY changes regarding information contained in this application, and I am responsible for following and abiding by the Coaches' Code of Conduct as outlined in the attached handout.

· · ·

· ·

I affirm that I have read and understand the above and that the information I have given is true. If I am the parent/guardian of a minor volunteer applicant, I am signing on behalf of my child/ward and the provisions in this application bind us both. I understand that in the event any false information is provided, I may be terminated from my volunteer position with SONC. Your Signature[or Parent/Guardian of Minor]:_________________________________________Date:___________________

Revised 2/7/2008

DISCLOSURE & AUTHORIZATION TO OBTAIN INFORMATION (for Adult Volunteers) ­ Page 3 of 3

In connection with my application to become a volunteer with Special Olympics Northern California, Inc. ("SONC"), I understand that, prior to or at any time after any acceptance of my volunteer application, a Consumer Report or Investigative Consumer Report about me (the "Report") may be requested by SONC for volunteer participation purposes from a consumer reporting agency, including from a consumer reporting agency known as ChoicePoint Services, Inc. ("ChoicePoint"). I understand that the information in the Report will be obtained by accessing public records from various local, state, and federal agencies to the extent permitted by law, including but not limited to my motor vehicle operation history and criminal history. I understand that the Report may include information as to my character, general reputation, personal characteristics, and/or mode of living. I also understand that information sought will include a search of the state and/or federal Sexual Offender Identification Line(s)or Registry(ies). I HEREBY VOLUNTARILY AND KNOWINGLY AUTHORIZE CHOICEPOINT TO SEEK INFORMATION ABOUT ME ON BEHALF OF SONC, AND AUTHORIZE SONC TO PROCURE AND USE THE INFORMATION PROVIDED BY CHOICEPOINT ABOUT ME (INCLUDING ANY INFORMATION OBTAINED FROM THE SEXUAL OFFENDER IDENTIFICATION LINE(S) OR REGISTRY(IES)) IN CONNECTION WITH MY SONC VOLUNTEER APPLICATION. I UNDERSTAND THAT SONC MAY USE THIS INFORMATION FOR VOLUNTEER PARTICIPATION PURPOSES, INCLUDING BUT NOT LIMITED TO ACCEPTANCE OR DENIAL OF MY SONC VOLUNTEER APPLICATION, MY SONC VOLUNTEER ASSIGNMENT OR REASSIGNMENT, AND ANY TERMINATION OF MY SONC VOLUNTEER STATUS. I ALSO HEREBY AUTHORIZE ANY ADMINISTRATOR, LAW ENFORCEMENT AGENCY, STATE AGENCY, LOCAL AGENCY, FEDERAL AGENCY, AND/OR OTHER PERSONS TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY MOTOR VEHICLE/DRIVING RECORD HISTORY, CRIMINAL HISTORY, OR ANY OTHER INFORMATION ABOUT ME AS REQUESTED BY CHOICEPOINT. In accordance with the federal Fair Credit Reporting Act, the California Consumer Credit Reporting Agencies Act, and the California Investigative Consumer Reporting Agencies Act, I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested for the Report. Further, I am entitled to know if my SONC volunteer application is denied because of information obtained by ChoicePoint or any other consumer reporting agency (a "Reporting Agency"). If so, I will be so advised in writing and be given the name and address of the Reporting Agency, including its toll free number, a statement that the action was based in whole or in part on information contained in the Report, and written notice that I have the right (i) if I request, to obtain within sixty days a free copy of the Report from the Reporting Agency; and (ii) to dispute the accuracy or completeness of any information in the Report furnished by the Reporting Agency. I further understand that upon my request with reasonable notice, ChoicePoint will supply me with investigative information in my file during normal business hours in person or upon written request, by mail or telephone as permitted by law. I also understand that ChoicePoint is a consumer reporting agency and it is ChoicePoint's policy to not be involved in or make decisions or recommendations concerning volunteers for SONC. I also understand that ChoicePoint does not sell or otherwise provide any of the information found in its background investigations to any other party. I further understand that any Report requested will be used strictly for permissible purposes. In addition, any assignment (or reassignment) as a volunteer for SONC will be conditioned on the receipt of satisfactory information as determined by SONC, and that to be considered for assignment as a SONC volunteer, I must authorize the procurement of the Report(s) and sign this Disclosure & Authorization to Obtain Information document. A photographic or faxed copy of this Disclosure & Authorization to Obtain Information document shall be as valid as the original.

I have read and understand this Disclosure & Authorization to Obtain Information document.

Your Signature: _________________________________________________________ (Your Signature Above Authorizes the Procurement of the Report)

(Print Your Full Legal Name as it Appears on Your State Driver's License or ID Card)

Date: _________________________

Last Name:____________________________First Name:__________________________Middle Name:__________________ Your Address:______________________________________City:_____________ County:________ State:________ Zip:______ Former Address if Less than One Year at Current Address:________________________________________________________ Date of Birth:______/_______/________ Driver's License No:_________________________ State Issued:__________________ List All Other Names Used:____________________________________________________________________________________ I understand that if any Investigative Consumer Report about me is prepared for SONC, I may request that a copy of the Report be sent to me within 3 business days of the date that SONC receives the Report. (Check a box below.) [ ] No, I do not wish to receive a copy of any Report about me that is prepared. [ ] Yes, I wish to receive a copy of any Report. ChoicePoint Services, Inc.* 2885 Breckenridge Blvd., Duluth, GA 30096 /PO Box 105108, Atlanta, GA, 30348* Tel: 1-800-845-6004

Revised 2/7/2008

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