Volunteer Application

Volunteer Application

Name

Date of Birth

Date

Address

Home Phone

Cell

Email

example@example.com

Next Kin/Emergency Contact

Relationship

Home Telephone

Cell

Physicians Name

Phone

Medical Concerns

Grace House reserves the right to contact parties listed on this form and to secure appropriate medical services in the event of a medical emergency. Grace House will not accept financial responsibility for seeking appropriate care.

Days/Nights Available

What shift(s) are you interested in?

Breakfast (6a-8a M-F) (7a-9a S-S)Sleep Overnight (10p-6a M-F) (10p-7a S-S)

How many times per month would you like to volunteer?

4x/month2x/month1x/monthOther

Community Service Related?

YesNo

How did you hear about the Grace House?

501 SW 1st Avenue Grand Rapids, MN 55744 Phone: 218.326.2790

www.gracehousemn.org Fax: 218.326.2878

Name

Home Phone

Cell Phone

Address

Are you registered with RSVP/Eldercircle?

YesNo

Age Range:

Under 2121-4041-60Over 60

What other volunteer/work experience have you had?

Have you at any time ever

Been arrested for any reason?Been convicted of, or pleaded no contest to, any crime?Engaged in, or been accused of, any child molestation, exploitation, or abuse?

*A background check will be done. Are you aware of:

Having any traits or tendencies that could pose any threat to children, youth, or others?Any reason why you should not work with children, youth or others?

If the answer to any of these is "yes" please explain in detail.

Do you need any special accommodations to perform duties?

YesNo

If you answered "yes" please explain

If you are representing an agency, what church or organization are you representing?

Applicant Verification and Release

I recognize that the organization to which this application is being submitted is relying on the accuracy of the information contained herein. Accordingly, I attest and affirm that all of the information that I have provided is absolutely true and correct. I authorize the organization to contact any person or entity listed in this application, and I further authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications. I voluntarily release the organization and any such person or entity listed herein from liability involving the communication of information relating to my background or qualification. I further authorize the organization to conduct a criminal background investigation. I have carefully read the policy and procedures of the organization, and I agree to abide by them and to protect the health and safety of guests of Grace House.

Signature

Date

I understand it is my responsibility to keep confidential all information that I may gain or become privy to as a Grace House volunteer. This includes, but is not limited to, any information regarding guests, administrative operations, and any other information accessed through organization records, meetings, or computer information system.

By reviewing and signing this form, I agree to abide by the following:

1. I will respect all individuals' rights to privacy and their confidentiality. I will not discuss or in any other way disclose any information concerning any individual I come into contact with at Grace House, guest, or otherwise.

2. I will respect the confidentiality of information regarding administrative operations. I will not discuss or in any other way disclose information concerning Grace House operations or administration outside the organization.

3. I agree to review and become familiar with any other organizational, state, or government policies/procedures, documents, and other materials that discuss and govern confidentiality and release of information.

I have read this agreement as well as Grace House's COVID 19 Protocol AND Return to Shelter Plan, understand its contents, and agree to comply with all of their terms. This signed agreement will become part of my personal file.

Signature of Volunteer

Date

Any violation of the above agreement will result in disciplinary action up to and including termination.

501 SW 1st Avenue Grand Rapids, MN 55744 Phone: 218.326.2790

Email: www.gracehousemn.org Fax: 218.326.2878

Background Investigation Consent

I hereby authorize Grace House and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for service, not, and if applicable, during the tenure of my service with Grace House.

I release Grace House and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name and all information contained herein is true and correct to the best of my knowledge.

Applicant Name (Please Print)

Date of Birth

Date

Applicant Signature

Date

Any Other Names Used/Known by

*NOTE: The above information is required for identification purposes only, and is in no manner used as qualifications for service. Grace House is an Equal Opportunity Employer, and does not discriminate on the basis of Sex, Race, Age, Handicap, and Or National Origin.

Grace House policy is to NOT accept an individual with crimes against children or crimes related to sexual misconduct.

501 SW 1st Avenue Grand Rapids, MN 55744 Phone: 218.326.2790

www.gracehousemn.org Fax: 218.326.2878

Reference (non family):