PCCS Volunteer Application
Legal Name
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First Name
Last Name
Chosen Name
First Name
Last Name
Chosen Pronouns
She/Her
He/Him
They/Them
Other
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Birthdate
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Month
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Day
Year
Date
Please indicate days and times that you are available to volunteer:
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Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies and sports:
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Do you have any physical limitations? If yes, please explain.
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Emergency Contact Name & Phone Number:
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It is the policy of the organization to provide equal opportunities without regard to sexual orientation, sex, gender, gender identity, race, color, religion, marital status, veteran status, age, national origin, HIV status, disability, or any other such category which is protected by federal, state or local regulations. Certain volunteer positions have an age requirement due to the responsibilities of the position.
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As a volunteer of our organization, I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and the organization, it's employees, and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problems which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis, and I am not eligible to receive any monetary payment or reward. By typing my name on the line below, I am agreeing to the above statements.
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Today's Date
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Month
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VOLUNTEER BACKGROUND CONSENT FORM
Prism Counseling &Community Services (PCCS) is committed to selecting and retaining the beststaff and volunteers to serve its youth. As part of the initial selectionprocess and on an on-going basis, PCCS will conduct background checks inaccordance with the following policy:
PCCS will conduct criminal background checks of all employees and volunteers, including minors, who have direct, repetitive contact with children. Name-based or fingerprint-based record searches may be used in any combination but shall, at a minimum, (a) verify the person’s identity and legal aliases, (b) provide a national Sex Offender Registry search, and (c) provide a national criminal record search. Such checks shall be conducted prior to employment and at regular intervals not to exceed twelve (12) months.
All background check findings shall be considered when making employment or volunteer decisions. It is the policy of PCCS that an employee or volunteer will be automatically ineligible for employment or volunteer service, if such individual: (a) refuses to consent toa criminal background check, (b) makes a false statement in connection with such criminal background check, (c) is registered, or is required to be registered on a State or National sex offender registry, (d) has been convicted of a felony consisting of: 1.murder,2. child abuse, 3. a crime against children, including child pornography, 4. spousal abuse, 5. a crime involving rape or sexual assault, 6. arson or 7. physical assault, battery, (e) has been convicted of a drug related offense committed within the last five years.
LEGAL NAME (INCLUDING MIDDLE INITIAL)
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First Name
Last Name
BIRTHDATE
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Month
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Day
Year
Date
DRIVERS LICENSE NUMBER (INCLUDE STATE):
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
GENDER
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RACE
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AFRICAN AMERICAN
ASIAN/PACIFIC ISLANDER
CAUCASIAN
HISPANIC
OTHER
I authorize Prism Counseling & Community Services to conduct a complete criminal history check as a basis of my placement as an employee or volunteer with the organization. I understand that I am to report any changes in my criminal history to Prism Counseling & Community Services.
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TODAY'S DATE
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Month
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Year
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VOLUNTEER AGREEMENT AND CONSENT TO DRUG AND/OR ALCOHOL TESTING
I hereby agree, upon a request made under the drug/alcohol testing policy of Prism Counseling & Community Services to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I other wise fail to cooperate with the testing procedures, I will be subject to immediate dismissal of volunteer duties. I further authorize and give full permission to have Prism Counseling & Community Services and/or its physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Prism Counseling & Community Services and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Prism Counseling & Community Services to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.
I understand that only duly authorized Prism Counseling & Community Services officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.
I will hold harmless the Prism Counseling& Community Services its physician, and any testing laboratory they might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including adverse action that might arise as a result of the drug or alcohol test, even if a Prism Counseling & Community Services or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the Prism Counseling & Community Services its physician, and any testing laboratory they might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above. This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.
I UNDERSTAND THAT PRISM COUNSELING &COMMUNITY SERVICES WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST UNDER THISPOLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDERCIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS ORALCOHOL IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCHTEST.
Prism Counseling & Community Services will conduct drug and/or alcohol testing under any of the following circumstances: FOR-CAUSE TESTING: The Company may ask a volunteer to submit to a drug and/or alcohol test at any time it feels that the volunteer may be under the influence of drugs or alcohol, including, but not limited to, the following circumstances: evidence of drugs or alcohol on or about the volunteer person or in the or volunteer’s vicinity, unusual conduct on the or volunteer’s part that suggests impairment or influence of drugs or alcohol or negative performance patterns. POST-ACCIDENT TESTING: Any volunteer involved in a volunteer duty accident or injury under circumstances that suggest possible use or influence of drugs or alcohol in the accident or injury event may be asked to submit to a drug and/or alcohol test. "Involved in a volunteer duty accident or injury" means not only the one who was or could have been injured, but also any volunteer who potentially contributed to the accident or injury event in any way.
If a volunteer is tested for drugs or alcohol outside of the volunteer context and the results indicate a violation of this policy, or if a volunteer refuses a request to submit to testing under this policy, the volunteer may be subject to appropriate disciplinary action, up to and possibly including discharge from volunteer opportunities. In such a case, volunteer will be given an opportunity to explain the circumstances prior to any final volunteer opportunity action becoming effective.
Signature
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TODAY'S DATE
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Month
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Submit
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