Summerhouse Houston Form

Form
Volunteer Application
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email *
example@example.com
Date

Month Day Year
Date
Do you have your own transportation? *

Yes No
Do you have valid auto insurance in the state of Texas? *

Yes No
Liability Only Full Coverage? *

Yes No
If hired, could you use your vehicle? *

Yes No

Employment History:

	Name of Company	Position	Dates

Volunteer History:

	Name of Company	Position	Dates

Education: High school graduate? Yes No Some college? Yes No College degree? Yes No - Degree: If yes, please complete Masters? Yes No - Degree: If yes, please complete
What experiences have you had with persons with disabilities?
Please note any special interests/skills/training you can offer:
Have you previously volunteered for Summerhouse Houston? *

Yes No
When?
Position?

Availability:

	Available
Weekdays:
Evenings:
Weekends:
Annual gala/Special events:

How did you hear about Summerhouse Houston?

Volunteer Houston Facebook Instagram LinkedIn Website School Referral
School Name
Referred by:
All the information on this application is accurate to the best of my knowledge. I understand that volunteering with Summerhouse Houston is not in any way an employment agreement, and that I will not receive payment for my time. I understand that if I am over 18, a criminal background check will be conducted prior to my volunteer assignment.
Signature of Volunteer *

Clear
Date *

Month Day Year
Date
VOLUNTEER—MEDICAL AND EMERGENCY INFORMATION
Name *

First Name Last Name
Date

Month Day Year
Date
Emergency Contact:
Name
Relationship
Home Phone
Please enter a valid phone number.
Cell/Work Phone
Please enter a valid phone number.
Emergency Contact:
Name
Relationship
Home Phone
Please enter a valid phone number.
Cell/Work Phone
Please enter a valid phone number.
I understand that I must provide my own medical/accident insurance. I understand that Summerhouse Houston provides no such coverage.
Signature *

Clear
Date *

Month Day Year
Date
Authorization is hereby given to the staff of Summerhouse Houston to obtain medical treatment for me in the event of an emergency.
Signature *

Clear
Date *

Month Day Year
Date
Policy on Confidentiality and Privacy
The success of direct member services as conducted by Summerhouse Houston is often dependent upon access to and review of past and current demographic, personal, and medical information. The trust between volunteers and members must be respected during direct communications and by adhering to professional codes of confidentiality. Volunteers working within a direct service program of Summerhouse Houston may have access to such information are required to abide by this policy on confidentiality. I have read and understand the above statement and agree to abide by Summerhouse Houston’s policy on confidentiality.
Signature *

Clear
Date *

Month Day Year
Date
Policy on Abuse and Neglect
Any person who believes that an individual is being abused, neglected, or exploited is required by law to report this information to the Texas Department of Protective and Regulatory Services Abuse Hotline, 1-800-252-5400, within 48 hours of the time one suspects the person has been or may be abused or neglected. Abuse and neglect include, but are not limited to, physical, emotional, or mental injury or failure to prevent such injury. If a volunteer witnesses what s/he considers to be abuse or neglect, s/he is required to inform the Program Director as soon as possible. The Program Director will then inform the Executive Director. An incident report must be turned in within 48 hours of any suspected abuse or neglect. If a volunteer is suspected/accused of abuse or neglect, s/he will be suspended from their position pending an investigation by the Program Director and until such final determination is made. Failure to comply with this policy is automatic grounds for dismissal.
Signature *

Clear
Date *

Month Day Year
Date
Media/Publicity Consent Form Volunteers
I give my consent for the release of any publicity pictures or videos by Summerhouse Houston that would assist in promoting and providing various services for persons with intellectual and other developmental disabilities.
Signature *

Clear
Date *

Month Day Year
Date
Volunteer Requirements and Participation Acknowledgement
Summerhouse Houston volunteers must meet the following requirements: 18 years or older Ability to pass a background check If working directly with members - commitment to at least 1 activity a week per semester (fall, spring, and/or summer) Must attend orientation and training Personal reliable transportation preferred; at minimum, volunteers need to be able to get to Summerhouse Houston or the location of the activity independently. If the volunteer does not have own transportation and meets at Summerhouse Houston, then he/she would need to participate in activities in which there is available space in Summerhouse Houston vans/cars. Maintain regular communication via text or email with Summerhouse Houston staff Compliance with Summerhouse Houston policies and rules Creative, outgoing, respectful, flexible, and willing to work with young adults with varying abilities I have read and understood the above requirements and certify that I meet each one. I acknowledge that if at any time I am no longer able to meet any requirement or cannot attend a certain activity, I will notify Summerhouse Houston staff immediately. I understand that my participation with Summerhouse Houston is voluntary, and I will not receive monetary compensation for my time volunteered. If I no longer comply with Summerhouse Houston policies and rules, I understand that I may be asked to no longer volunteer with Summerhouse Houston.
Signature *

Clear
Date *

Month Day Year
Date
To complete this process please download the following Background Check Authorization form, fill it out, and upload it to this form.
Completed Background Check *

Cancel of
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Form

Volunteer Application

VOLUNTEER—MEDICAL AND EMERGENCY INFORMATION

Emergency Contact:

Emergency Contact:

Policy on Confidentiality and Privacy

Policy on Abuse and Neglect

Media/Publicity Consent Form Volunteers

Volunteer Requirements and Participation Acknowledgement