References/former employers/teachers:

List two people we may contact in case of emergency:

Services for Victims of Domestic Violence and Sexual Assault Support for the Central Peninsula's Families

I give my child LeeShore Center under the supervision of agency staff. I understand The LeeShore Center adheres to strict rules of confidentiality and all volunteers providing services or work at LeeShore are asked to sign a Confidentiality Agreement form stating they understand the agency's Confidentiality policies.

permission to volunteer at The

The LeeShore Center Mission Statement

To promote healthy families and a violence free community while providing

a safe haven for victims of domestic violence and sexual assault: by

treating all people with respect, creating an educated and aware public; and by empowering those that have been oppressed while striving

to eliminate domestic abuse and sexual assault

It is the policy of The LeeShore Center to maintain client confidentiality. Clients are advised that at no time will information be released regarding their involvement in the program except for the following reasons: 1. The client signs a written Release of Information form authorizing information to be released to a specific agency for a specific purpose. The form is person and time specific. 2. A court order compelling The LeeShore Center staff to release records. 3. LeeShore Center staff are mandatory reporters of known or suspected child abuse or vulnerable adult abuse. 4. In cases where staff believe there is eminent danger of injury to the client or to another The following information will provide further guidelines on the issue of client confidentiality. A. No identifying information about clients (names, addresses, social security numbers, etc are to be revealed except within the confines of the program. B. Discussing details of the case outside the confines of the program, even through names, addresses, and social security number are not revealed, is considered a breach of confidentiality. C. The fact that a case has been made public through any of the news media does not alter the fact that the client still has confidentiality privileges. An orientation regarding confidentiality is conducted for all new staff and volunteers. Each new employee and volunteer will receive information on program confidentiality and will be asked to sign a confidentiality agreement. It is included in the agreement that should a staff person or volunteer breach confidentiality, they will be dismissed at the Executive Director's discretion.

have received and read The LeeShore Center's , Confidentiality Policy Summary. I agree to maintain client confidentiality as described in the summary. I understand that dismissal from paid or volunteer employment at The LeeShore Center may result if client confidentiality is breached.

The role of a volunteer is important in meeting the needs of The LeeShore Center. In volunteering my time and energy, I understand The LeeShore Center is not liable for payment to me for work I perform on a voluntary basis.

As a volunteer at The LeeShore Center, I realize that I am bound to a code of ethics similar to that which binds the paid staff members. I will not discriminate against any individual, family, or group seeking The LeeShore Center services due to: race, handicap, sex, age, marital status, economic status, veteran status, sexual preference, religion, national origin, or political affiliation. I will respect the privacy and safety of all agency clients by abiding to The LeeShore Center's confidentiality policy.

I promise to take to my volunteer work an attitude of open mindedness, to be willing to be trained for it, and to bring to it interest and attention. I believe that my attitude toward volunteer work should be professional.

I understand that should I not be able to be present for the time I have scheduled, I will give my supervisor prior notice of my absence.