Volunteer Information Sheet

Volunteer Information Sheet

Thank you for your interest in volunteering with Clive Community Services. To make every responsible effort to provide a safe environment for our volunteers and the patrons we serve, Clive Community Services requires the following information:
PERSONAL INFORMATION
Volunteer Name:*

First NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number:
Please enter a valid phone number.
Email:*
example@example.com
Preferred Method(s) of contact:*

Call Cell NumberText Cell NumberEmailCall Work NumberCall Home Number
I am a(n) (check all that apply):*

AdultYouth (Minimum volunteer age 14)Silver CordCompleting a service project (enter who the project is for in box below)
If you are a youth volunteer please enter your date of birth.
Employer:
Profession:
School:
Date of birth:
How did you hear about volunteering with us?
EMERGENCY CONTACT
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Relationship:*

NON-DISCRIMINATION POLICY

Clive Community Services does not engage in discrimination or harassment against any person because of race, color, religion, sex, national origin, ancestry, age, order of protection order, genetic information, marital status, disability, sexual orientation (including gender identity), unfavorable discharge from the military, or status as a protected veteran, and will comply with all federal, state, and local nondiscrimination, equal opportunity, and affirmative action laws, orders and regulations.
I agree to follow the above CCS' non-discrimination policy?*

YesNo

VOLUNTEER DISCLOSURE STATEMENT
Other than a minor traffic violation, have you ever been convicted* or any crime, misdemeanor or felony?*

YesNo
If yes, list date & description of violation:
*The term “convicted” includes a guilty plea,a plea of nolo contendere or no contest, a deferred judgment or adjudicationand an adjudication of guilt or delinquency as a minor. Note: Convictions will not necessarily bar you from service as avolunteer. We will consider the number,nature seriousness and recency of the convictions in making our decision.
Have you ever been convicted*, or had an administrative finding, of violating any law involving child abuse, sexual abuse, physical abuse, sexual harassment or exploitation, or any other crime related to children?*

YesNo
Do you currently have charges pending relating to child abuse, sexual abuse, physical abuse, sexual harassment or exploitation, or any other crime related to children?*

YesNo
Are you now, or have you ever been, listed on the sexual offender registry, child abuse registry or adult abuse registry?*

YesNo
Any “yes” answer requires a more in-depth interview with the Executive Director and may also require the applicant to sign a waiver giving CCS permission to conduct an Iowa criminal history record check.

CCS reserves the right to conduct random background investigations of volunteers who have not answered “yes” to any of these questions. If a volunteer is selected for a random background investigation, the volunteer will be required to sign a waiver giving CCS permission to conduct the investigation.

The information provided above is accurate and complete.
Volunteer Initials:*
Date*

MonthDayYear
Date

CONFIDENTIALITY STATEMENT

Volunteers are expected to maintain the confidentiality of our patrons’ information. This expectation is crucial to the safety and wellbeing of every person in our program. If you have a concern or suggestion regarding a patron, please discuss it with Lisa Earles, Executive Director, director@clivecommunityservices.com.
Signature of Volunteer:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Volunteer Information Sheet

NON-DISCRIMINATION POLICY