Volunteer Application
Thank you for your interest in volunteering with New Hope! Please complete the form below so we can get to know you and match you with the best opportunities. If completing this by hand, please print clearly so we can read your information to get in touch with you. If we can’t read it, we can’t reach you. Thank you!
Name
First Name
Last Name
Previously Used Name(s) (Maiden, etc)
First Name
Last Name
Previously Used Name(s)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please Select One
Male
Female
Other
Social Security Number (Used for required background checks; kept confidential)
Previous Names Used (Including Maiden Name)
I would like to volunteer with (check as many as you'd like):
Atlantic Bargain Shoppe
Carroll Bargain Shoppe
Coon Rapids Bargain Shoppe
Jefferson Bargain Shoppe
Perry Bargain Shoppe
One-to-One
Driver/Companion (Church,etc.)
Special Events
Gardening
Other
Days/times you prefer to volunteer:
Previous volunteer experience, if any:
Are you related to /acquainted with an individual who receives services from New Hope? Name(s) and relationship.
Do you have friends or relatives employed with New Hope? Please list name and relationship.
Do you have hobbies, skills, talents or interests that may be useful or of interest when volunteering?
If you are a student, please list your school and current grade level.
Emergency Contact Information
This person may be contacted in the event of an emergency
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship To You
Personal Reference Information
Personal Reference, other than a relative, list one personal reference (employer, former employer, school, church, etc.) I am authorizing New Hope to contact my reference in reference to my volunteer application.
Name
First Name
Last Name
Relationship to You
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Background & Safety Check
Have you ever been convicted of a criminal offense?
*
Yes
No
Have you ever been charged with neglect, abuse or assault?
*
Yes
No
Has your driver’s license ever been suspended or revoked?
*
Yes
No
If you answered yes to any of the background and safety questions, please explain:
*
Agreement
I consent to a criminal background check and a motor vehicle records check. I certify the information provided on my application is true and complete to the best of my knowledge. I have not withheld any information that could affect my application unfavorably, if included. I understand New Hope may refuse to allow me to volunteer if I provided any incorrect information or omission. I understand my volunteer service can be modified or terminated without notice or cause, at any time.
I HAVE READ AND UNDERSTAND THIS DISCLOUSURE AND AUTHORIZATION TO OBTAIN INFORMATION
*
Yes
Signature
*
New Hope Volunteer Statement of Confidentiality & HIPAA Acknowledgement
Client information is of a private nature and should be considered confidential.Under the Health Insurance Portability and Accountability Act (HIPAA), there is a list of personal identifiers known as Protected Health Information (PHI). This list includes client name, address, birthdate, telephone number, email address, social security number and medical record number.Knowingly and improperly disclosing PHI of individuals served by New Hope may result in termination and possible criminal proceedings.HIPAA Penalties: Up to $50,000 and one year in prison for “knowingly and improperly” obtaining or disclosing PHI. Up to $100,000 and five years in prison for obtaining PHI under false pretenses. Up to $250,000 and ten years in prison, if done with an intent to sell, transfer or use for commercial advantage, personal gain, or malicious harmI understand that any information about an individual served by New Hope is strictly confidential. In conjunction with my role as a volunteer, I agree to use any individually identifiable information that I become aware of only in my capacity as a volunteer and will not disclose this information to any other individual or agency.Taking photos and/or videos of individuals served by New Hope with personal phones or cameras is not allowed. Volunteers at any of the Bargain Shoppes will maintain confidentiality concerning donor and customer information.I have received training on the New Hope Confidentiality Policy. I agree and will abide by these provisions. I understand that any violation of New Hope’s Confidentiality Policy may result in disciplinary action, up to and including dismissal from my volunteer position; and that civil or criminal penalties may apply.
Volunteer Signature
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