VOLUNTEER APPLICATION

The KC Shepherd's Center provides programs, leadership and advocacy to help both active and homebound older adults live healthy, engaged and independent lives.

Criminal Background and DMV Check Release

I hereby certify that the facts set forth during the volunteer application process are true and complete to the best of my knowledge. I understand that if during volunteering application, I falsified statements during the application process may result in dismissal. I release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I hereby authorize KC Shepherd’s Center to perform a background check as a condition of my being a volunteer.

KCSC Conflict of Interest Policy

Associates of KC Shepherd’s Center (KCSC) must act in all matters in a manner that will safeguard the reputation and integrity of KCSC and will preserve and strengthen public confidence in KCSC activities.  Members of the Board of Directors, Staff and Volunteers are restricted from any activities, situation or circumstance that may result in a personal gain for themselves or for a relative. Such conflicts would exist when an individual directly or indirectly, or one of their relatives: 
 
Owns any beneficial interest or serves as a director, officer, employee, consultant or agent in an organization which has current or prospective business transactions with KCSC. 
 
Seeks or accepts any gifts or favor from any person or organization which has current or prospective business with KCSC, if the acceptance or prospect of future gifts or favors may tend to limit or restrict an individual from acting with absolute impartiality with respect to such organization in current or future business transactions. 
 
Uses for personal gain or to benefit others, the property, records, services, name, emblem or endorsement of KCSC. 
 
Sells or offers for sale for personal gain any information gained through affiliation with KCSC. 
 
Accepts payment of any kind (including gifts, cash, discounts, concessions, services, or other similar item of benefits) for services rendered as part of their employment or volunteer service. 
 
Participation in any activity prohibited by this policy can result in the termination of employment or volunteer service. 

 

 

Publicity Release Form

In return for being allowed to participate in KC Shepherd’s Center volunteer activities and all related activities, including any activities related to participation (“Volunteer Activities”), the undersigned Volunteer or Parent/Legal Guardian of Volunteer hereby grants to KC Shepherd’s Center rights and permission to use, publish, broadcast and/or copyright the use of Volunteer’s name, voice, photograph and/or likeness, caricature, and information, in its current form or as retouched, digitized, cropped, altered, or modified in any way, in any and all advertising, promotional, or other materials based upon or derived from the Volunteer Activities in any manner, in any media whatsoever for any and all purposes, including but not limited to:

•advertising
•promoting or publicizing services
•social media and websites
•newsletters
•recruitment pieces
Volunteer understands these will be published without additional compensation.
Volunteer understands that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the Volunteer Activities take place.

KC Shepherd’s Center (KCSC) recognizes that volunteers may occasionally use their own personal vehicle to complete organizational business. A volunteer using a personal vehicle assumes primary responsibility for any use of that vehicle for organizational business. The volunteer shall be solely responsible for any physical damage to the their personal vehicle and if the volunteer
becomes subject to an auto liability claim resulting from the use of the volunteer's personal vehicle for organizational business, the volunteer's personal insurance will be primary while KCSC’s Hired and Non-Owned Liability coverage will provide secondary coverage.

KCSC will not reimburse volunteers for expenses not necessary for the organization’s purposes, such as:
• Parking tickets;
• Vehicle repairs and maintenance;
• Fines for moving violations; and
• Vehicle towing charges.

A volunteer shall only be authorized to use a personal vehicle for carrying out KCSC business upon certifying that the volunteer meets the following conditions:
• The volunteer possesses a valid driver's license;
• The volunteer’s vehicle is legally registered;
• The volunteer’s vehicle has passed its most recent vehicle safety inspection (if applicable) and is maintained;
• The volunteer holds current state-required minimum automobile liability insurance issued by a reputable insurer licensed to provide insurance in the state of Missouri or Kansas.

All volunteers driving a personal vehicle to carry out business on behalf of the KCSC must follow all of the rules of the road. All vehicle operators are responsible for using the vehicle in a safe and responsible manner while conducting organizational business and are to abide by all traffic laws while operating a vehicle.

Personal Vehicle for Organizational Use Policy for Volunteers
• Drivers and all passengers are required to wear seatbelts at all times, with no exceptions.
• In order to prevent injury to the operator of the vehicle, as well as bystanders, all cargo inside or on the vehicle must be secured and stored safely at all times. This will prevent unintentional movement, damage to the vehicle, and/or cargo.
• Any operator who has their driver's license revoked or suspended shall notify KCSC immediately. No volunteer with a suspended license or expired insurance may operate a vehicle on KCSC busines until the license and/or insurance has been reinstated.
• No vehicle operator shall drive a vehicle while under the influence of alcohol, marijuana, or any other intoxicating drug.
• Use of illegal drugs is strictly prohibited, and operators are not to be under the influence of prescription drugs or over-the-counter medications that may cause drowsiness and other forms of impairment that prohibit the safe usage of motorized vehicles.
• Usage of all handheld devices (examples: cell phones, GPS) is strictly prohibited while driving. Cell phone usage, including hands-free is prohibited while operating a vehicles.

I acknowledge that I have the KC Shepherd’s Center Personal Vehicle for Organizational Use Policy for Volunteers and understand that it is my responsibility to be familiar with and abide by its terms. I further acknowledge and agree to abide by the above-stated rules, guidelines, and requirements,
including that the organization is not responsible for physical damage to my car and that my automobile liability insurance will be primary.

Volunteer Confidentiality Agreement

• I acknowledge and confirm that as a volunteer I may acquire information on the organization, its clients, staff and volunteers, and about certain matters and things which are of a confidential nature and that such information is the exclusive property of the organization and will remain in the strictest confidence.
• I affirm that the information referred to above could be used to the detriment of the organization and the volunteer activities and thereby undertake to treat as confidential all information, contracts or resources. I agree not to disclose the same to any third party either during the term I am volunteering for the organization or at any time thereafter unless required by law to do so.
• I agree that any knowledge gained as a result of my position will remain in strictest confidence.
• I acknowledge that any client contributions are confidential. I agree that I will give all monies to the KCSC Program Manager or Executive Director without disclosing the name of the client who contributed. Furthermore, to assist KCSC, I will indicate on the volunteer sign-in sheet that a contribution in said amount was given to either person.
• I agree to exercise due care to ensure that any information I may give to others in the course of my duties as a volunteer or otherwise is information that has been pre-approved by KC Shepherd’s Center.
  I agree I will not discuss the details of my volunteer work with any representatives of the media or publicize any of the confidential aspects of my work orally or by written work or any other medium of communication.
• I confirm that I have read the above statements and agree with them and I will therefore adhere to all confidential requirements contained in this agreement or as may be otherwise directed to me in writing by my supervisor as a volunteer.

Area Agency on Aging  Conflict of Interest Screening for Volunteers Involved with the Older Americans Act Programs: 

Individual Conflict of Interest 
 
Per OAA Final Rule, 45 CFR 1321, all Area Agency on Aging staff, volunteers, Board Members, and Advisory Council members who have responsibilities relating to Title III programs must be screened for Conflicts of Interest (COI) before performing the AAA functions and annually thereafter. 
 
Individual COI exists if (1) An employee, or immediate member of an employee’s family, maintaining ownership, employment, consultancy, or fiduciary interest in a Title III program organization or awardee when that employee or immediate family member is in a position to derive personal benefit from actions or decisions made in their official capacity; (2) One or more conflicts between the private interests and the official responsibilities of a person in a position of trust; (3) One or more conflicts between competing duties; and (4) Other conflicts of interest identified in guidance issued by the Assistant Secretary for Aging and/or by State agency policies. 
 
Immediate family pertaining to conflicts of interest, means a member of the household or a relative with whom there is a close personal or significant financial relationship. In the past 12 months, have you or an immediate family member: 

Answering “Yes” to any of these questions indicates a potential conflict of interest. If a conflict of interest is identified, the “Conflict of Interest Identification, Removal, and Remedy Form” must be completed and submitted to the AAA Director for review and approval.   Failure to identify and remove a conflict of interest could result in disciplinary action or termination of employment. 
 
I certify that I have read and understand this COI form and have no conflicts. 
 
I certify that I have read and understood this COI form and have notified the AAA Director of any potentially perceived or actual conflict of interest.