WCU Camp Abilities HR Volunteer Forms

WEST CHESTER UNIVERSITY Volunteer Authorization Application Contact Information

Applicant Information
Name*
Street Address*
City State Zip Code*
Phone Number*
WCU Email Address & Personal Email*
example@example.com
Emergency Contact*
Phone Number*
Relationship*
Year?
Program Name: Camp Abilities PA @WCU

Program Director: Dr. Beth Foster

Expected Dates of Service: Memorial Day Weekend Thursday til Monday

Description of Your Volunteer Services: Volunteer coach to assist and work with athletes with vision loss at the Camp Abilities Sports Camp
Your Work Experience*
Your Education*
Are you currently enrolled at West Chester University*

YesNo
Background Clearances: All background clearances must be submitted before dates of service. PASSHE's Board of Governors Policy 2014-01-A, Protection of Minors, requires the following background checks for all Volunteers:

X PA State Criminal X PA Child Abuse X FBI Fingerprint OR Volunteer Exemption
Minors: Please check if you are under the age of 18. Minors are not required to complete background clearances. Parent approval required if minor. Parent Name print here
Date

MonthDayYear
Date

Authorized Adults and Program Staff Code of Conduct
Authorized adults or program staff should be positive role models for minors and act in a responsible manner that is consistent with the mission of West Chester University. Authorized adults and program staff are required to comply with all applicable laws and PASSHE Board of Governors' and university policies. Authorized adults and program staff working in programs covered by this policy must follow these expectations.

a. Avoid making sexual comments or jokes to minors, sharing or facilitating access to sexually explicit material with minors, or engaging in behavior which could be objectively construed as sexual in nature with minors.

b.Refrain from engaging minors in conversations that could compromise the role as authorized adults or program staff. Examples of subject matter that should be avoided includes sharing highly personal or otherwise sensitive information about one's self, such as personal financial or workplace challenges, past drug or alcohol use, and personal romantic relationships.

c. Physical contact with a minor program participant should generally only be in the open, and in response to the minor's needs, for a purpose that is consistent with the program's mission and culture, or for a clear educational, developmental, or health-related purpose. If a minor resists or objects to being touched the minor's wishes should be respected. Physical restraint of a minor should only be used if required by a Program Administrator and only as a last resort to protect a minor or other minors from physical harm.

d. When speaking to minors, language that could be taken or misconstrued as demeaning, intimidating, or bullying should be avoided; exploitative or otherwise abusive language should also be avoided.

e. Rely on group and supervised settings for contact with minors, as opposed to one-on-one settings. If unsupervised one-on-one settings are required in certain situations, good judgment in choosing the location and duration of the one-on-one setting is essential.

f. When transporting minors in a vehicle, always have at least two authorized adults or program staff present in the vehicle.

g. Inviting minor program participants to your home or other non-public locations, or meeting with minor participants outside of program hours should also be avoided.

h. Gifts should never be given to minor program participants or their families, as they may be viewed as inducement.

i. Refrain from bringing alcohol or controlled substances to University premises, reporting for work in a program while under the influence of alcohol or controlled substances. Never provide alcohol or controlled substances to minors.

j. Refrain from providing or offering to provide medications, including both prescription and over-the-counter medications to minors participating in programs unless authorized by the Program Administrator in accordance with the programs medication management guidelines.

Violations of any of the forgoing shall be reported to the Program Administrator immediately.

I have read the Authorized Adults and Program Staff Code of Conduct and I agree to abide by all the terms and conditions.
Program Volunteer/Staff Signature*

Clear
Date*

MonthDayYear
Date
Program Volunteer/Staff Name*
Program/Camp Name: Camp Abilities PA @ WCU

Notice of Requirements as a Mandatory Reporter of Child Abuse
Definitions

➢ Minor/Child - A person under 18 years of age.

➢ Child Abuse

o Physical Abuse – Acts or omissions that cause, or fail to prevent, a serious physical injury to a child.

o Sexual Abuse - Includes, but is not limited to, rape, sexual assault, molestation, incest, indecent exposure, or otherwise exploiting a child in a manner in which the child is used for gratification or sexual enjoyment by another person.

o Emotional or Mental Abuse - Acts or omissions that have an actual or likely severe negative impact on a child’s emotional and behavioral development, including those resulting from persistent or severe emotional mistreatment.

o Neglect - A severe or persistent failure to provide for a child’s physical, emotional, or basic needs.

Scope

1. ALL University employees are Mandated Reporters of Child Abuse per West Chester University’s policy, Protection of Minors Policy, effective 07/01/2015.

2. “All employees” includes all individuals who are employed by or perform services (independent contractors, interns, and volunteers) for the University.

3. Programs include:

a. University or Non-University sponsored programs on campus; and

b. Programs under the direction of the University at off-campus locations; and

c. Programs and activities limited to daily activities or those that involve the housing of minors.

Reporting Child Abuse

1. All mandated reporters shall call 911 for an in-progress child assault.

2. All mandated reporters shall make an immediate report of suspected child abuse to the Department of Human Services (DHS) Childline by calling 1-800-932-0313.

a. See West Chester University’s Policy, Protection of Minors Policy, for specific guidance.

b. Immediately following the report to DHS the mandated reporter must notify the West Chester University Police Department of Public Safety in person or by calling 610-436-3511.

3. Immediately following the report to WCU Public Safety, the mandated reporter must also report the suspected abuse to the University division head with senior administrative responsibility for the program or facility where the suspected abuse occurred.

Other

➢ Intimidation or retaliation for having reported child abuse is prohibited.

o Please contact William Helzlsouer, Associate Vice President/Chief Human Resources Officer, at 610-436-3109 with any concerns.

➢ University mandated reporters who willfully fail to report suspected child abuse may be subject to disciplinary action, up to and including dismissal from employment. Mandated reporters may also be subject to criminal prosecution pursuant to the Child Protective Services Law, 23 Pa.C.S. §6319, for willfully failing to report suspected child abuse.

➢ Employees and volunteers are required to provide written notice to the employer if:

o Arrested for or convicted of a reportable offense listed in West Chest University’s policy, Policy on Employee Criminal Background Screening or

o Named as a perpetrator in a founded or indicated report of child abuse.

o The employee or volunteer shall provide such written notice within 72 hours of arrest or conviction.
Receipt of Notice of Requirements as a Mandatory Reporter of Child Abuse

I understand that I am a Mandated Reporter of Child Abuse per West Chester University’s policy, Protection of Minors Policy. I have reviewed the requirements of this policy and acknowledge my responsibility as a Mandatory Reporter of Child Abuse. I further acknowledge that I am responsible to self-report through a written report to West Chester University if I am arrested for or convicted of a reportable offense listed in West Chester University’s policy, Policy on Employee Criminal Background Screening, or if named as a perpetrator in a founded or indicated report of child abuse. I further acknowledge that I have also received West Chester University’s policies and consent to these terms and conditions.
SIGNATURE*

Clear
DATE*
Name*

First NameLast Name
EMAIL*
example@example.com
ADDRESS*
TELEPHONE NUMBER*
APPLICANT FOR: Volunteer
DEPARTMENT: Secondary Education and K12 Health and Physical Education
Should be Empty:

WEST CHESTER UNIVERSITY Volunteer Authorization Application Contact Information

Authorized Adults and Program Staff Code of Conduct

Notice of Requirements as a Mandatory Reporter of Child Abuse

Receipt of Notice of Requirements as a Mandatory Reporter of Child Abuse