Volunteer Application

Volunteer Application
Westside Domestic Violence Shelter 311 S. Villa Ave. Willows, CA 95988
Name

First NameLast Name
D.O.B
Phone #
E mail
example@example.com
I am interested in supporting

GroundskeepingDonation OrganizationAdministrative AssistanceGrant WritingGroup ClassesOther:
My Applicable skills/training include
I am willing to complete the 40 Hour Domestic Violence Advocacy Certification Course

YesNo
Volunteer Confidentiality Agreement

As a volunteer working in the shelter, you will have access to various types of restricted confidential information in the course of your work. Examples are victims and their children and the location of the shelter. To accept an engagement at the shelter is to accept responsibility to preserve the confidentiality of the location and people you may observe.

As it is a federal crime to disclose the location of the shelter, to deliberately misuse, damage the integrity of, and/or breach the confidentiality of information and/or persons could be cause for charges against you.

I have read and understand the above statements regarding the confidentiality of dataI

may have access to in the course of my contractual relationship at the shelter. I have discussed any questions I have about these statements with my advisor. I understand the special nature of the Shelter, the importance of confidentiality in these roles, and agree to adhere to policy regarding preservation of the confidentiality and integrity of the shelter.
Participant Signature

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Date

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