A Heart's Key Communal Care Alliance Volunteer Application

VOLUNTEER APPLICATION

All information is held strictly confidential. This form must be completely filled out. The information is vital to your acceptance and possible placement as a volunteer.
Type a question

This is my first time to volunteer at A Heart's Key Communal Care AllianceI am a returning volunteer to A Heart's Key Communal Care AllianceI have served in other capacities at A Heart's Key Communal Care Alliance
Today's Date

MonthDayYear
Date
First Name:
Last Name:
Date of Birth (must be 18 years of age to volunteer)

MonthDayYear
Date
Second Language (If any):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you been resident of Indiana?
If you have live in Indiana less than 5 years please list the previous addresses including state you resided in below.
Please list any previous states and addresses you have resided.
Phone Number (Cell):
Phone Number (Home)
Please enter a valid phone number.
Email:
example@example.com
Emergency Contact and Relation:
Phone:
Educational Background:
Are you currently employed? If yes, place of employment and job title?
Previous Employment/Volunteer Experience or Skills:
Are you or have you been a client at the A Heart's Key Communal Care Alliance within the last year? Yes/No

YesNo
At what times are you interested in volunteering?

Weekdays/AMWeekdays/PMAny DayWeekendsEvents Only
Hours available:
I am only available on (select days)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Background

If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any future risk of embarrassment upon disclosure.
Have you ever been convicted of or pleaded guilty to any crimes (including crimes of record which have been expunged and pleas of 'no contest'), including municipal, state and federal?*

YesNo
If yes, please explain:
I understand that a criminal background must be completed and passed before being accepted as a volunteer and that said information will be kept confidential.
Have you ever been sued in a civil court of law where the allegations in the suit involved illegal, inappropriate, or sexual conduct?*

YesNo
If yes, please explain:
I understand that a criminal background must be completed and passed before being accepted as a volunteer and that said information will be kept confidential.
Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order?*

YesNo
If yes, please explain:
I understand that a criminal background must be completed and passed before being accepted as a volunteer and that said information will be kept confidential.
Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as a volunteer, due to a complaint(s) of sexual, physical or verbal abuse?*

YesNo
If yes, please explain:
I understand that a criminal background must be completed and passed before being accepted as a volunteer and that said information will be kept confidential.
A photo I.D. (preferably Drivers license, Passport etc.) will be required to be shown at the interview to verify that your photo and name match the name on this application and background check. Please also upload a current photo of yourself (headshot). Please attach a copy of your photo ID

(ex: drivers license, passport, school or work photo ID)
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Applicant Signature:

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VOLUNTEER APPLICATION
1.How did you hear about the A Heart's Key Communal Care Alliance?
2.Why do you want to volunteer at A Heart's Key Communal Care Alliance?
3.Please list all your areas of interest: Administrative, Fund Raising, Event Planning, Marginalized Community Advocate, Vulnerable Population Advocate, Community Outreach.
4.What skills and personal attributes do you have that you could contribute to A Heart's Key Communal Care Alliance? Such as Graphic Design, Web Design, Writing, Advocacy, Training, Facilitation, Event Planning, etc
Have you received licensing or certification in any of the following?

CPRFirst AidNurse`EMTCNA/ HHACounseling or TherapyyPhysician
5.What do you hope to gain from your volunteer experience?
6.Please describe any previous experience working with vulnerable populations, diverse cultures and /or any relevant experience, work, or coursework (paid/unpaid)?
7. Following Rules: How well do you follow rules and respond to authority?

PoorlyFairly WellWellVery Well
8.Do you have a car available for reliable transportation?
9. Do you have any medical conditions or concerns, or are you taking any medications that you would like to share to better help us support you to be an effective volunteer?

YesNoPrefer not to answer
If yes, please explain
Personal References* (required for first time volunteers only)

No former employers or relatives. Please notify your references that they will be contacted via email or phone. Your application will not be processed until references have been checked.
Reference 1: Name*

First NameLast Name
Reference 1: Email*
example@example.com
Reference 1: Phone Number*
Please enter a valid phone number.
Reference 2: Name*

First NameLast Name
Reference 2: Email*
example@example.com
Reference 2: Phone Number*
Please enter a valid phone number.
Reference 3: Name*

First NameLast Name
Reference 3: Email*
example@example.com
Reference 3: Phone Number*
Please enter a valid phone number.
VOLUNTEER ACKNOWLEDGEMENT, RELEASE, AND WAIVER
Acknowledgement, Release, and Waiver
NOW THEREFORE, for good and valuable consideration, the receipt and sufficiency of which the parties acknowledge, the parties agree as follows:

1.Supervision and Training. Volunteer agrees that, while participating in the Volunteer Activities, Volunteer will be subject to the supervision and will follow the instructions of A Heart's Key Communal Care Alliance, its employees, officers, and agents. Volunteer agrees to receive any and all training required by A Heart's Key Communal Care Alliance prior to participating in the Volunteer Activities.

Volunteer understands that none of the documents, policies, procedures, actions, statements of A Heart's Key Communal Care Alliance Leadership or their representatives and agents used during the volunteer application process is deemed an offer for a contract or in fact a contract, real or implied. If accepted as a volunteer, Volunteer agrees to conform to the rules, regulations, policies, and procedures while serving as a volunteer, and understand that such compliance is a condition of remaining a volunteer.

2.Participation Is inA Heart's Key Communal Care Alliance Sole Discretion. Volunteer acknowledges that Volunteer’s participation in the Volunteer Activities is a privilege, not a right, and A Heart's Key Communal Care Alliance, its employees, officers, or agents, may, in their sole discretion, decline to allow Volunteer to participate in any of the Volunteer Activities for any reason.

3.No Employment or Compensation.
Volunteer understands that submission of an application does not guarantee an acceptance as a volunteer. Volunteer further understands that should the organization extend an offer as a volunteer, it is for no specific duration and may be revoked by the organization, or volunteer at any time, with or without cause. Volunteer acknowledges and agrees that this Release does not constitute an employment contract and does not entitle Volunteer to later employment with A Heart's Key Communal Care Alliance. Volunteer acknowledges that his/her/their services rendered in connection with the Volunteer Activities are being donated and that Volunteer is not and will not be entitled to, and Volunteer does not expect, any present or future salary, wages, reimbursement, compensation, or employee benefits as a result of providing such services.

4.Confidentiality. I agree to protect the confidentiality of A Heart's Key Communal Care Alliance clients, volunteers and employees. Information given to me by a client, volunteer or staff member will not be given to any agency or person without the expressed written consent of the person or guardian of the person to which the information pertains. Where it is deemed necessary to give an agency, client or other person the name of any A Heart's Key Communal Care Alliance volunteer, I agree to use the first name only. The release of any contact informationshould be cleared by the owner of such information or the Director of Programs. General policy is to take a name and phone number and give the message to the intended recipient. I also agree to respect the confidentiality of any agency and its clients I may be working with and agree to follow their established policy and procedures.

5.Grant of Right to Use Image, Audio, and Video. Volunteer acknowledges that one or more of A Heart's Key Communal Care Alliance, its employees, officers, and agents, may cause still photographs, audio recordings, and/or audio-video recordings (collectively, the “Recordings”) to be made of Volunteer’s participation in the Volunteer Activities. Volunteer grants to A Heart's Key Communal Care Alliance and their assigns, licensees, and successors the right to use the Recordings, including without limitation any Recordings containing Volunteer’s voice, image, picture, portrait or likeness, throughout the world and in perpetuity, but only for purposes of promoting A Heart's Key Communal Care Alliance nonprofit and/or charitable activities. The grant contained in the immediately preceding sentence applies to all forms and media, including composite or modified representations, and Volunteer waives the right to inspect or approve any version of Volunteer’s voice, image, picture, portrait or likeness prior to publication.
6.Volunteer’s Representations and Warranties regarding Criminal Conduct.

Volunteer understand that for A Heart’s Key Communal Care Alliance, it has had to agree to abide by certain policies and parameters established by A Heart's Key Communal Care Alliance, including strict policies against any form of abuse, and that violation of these policies may be cause for dismissal. Our organization is bound by law to report allegations of abuse or any inappropriate sexual contact to the proper authorities. ALL reporting is kept confidential, by law. All volunteers must commit to immediately report any behavior that seems suspicious, questionable, abusive or inappropriate. Volunteer represents and warrants that he/she/they has never been convicted of or pled nolo contendere to, and is not currently under investigation for, a crime of violence, including, but not limited to assault, child/elder abuse or neglect, child abduction, or kidnapping, nor has Volunteer been ordered by a court to receive mental health treatment in connection with any of the foregoing.

Volunteer understands that he/she/they will be required to submit to a background check as a condition of acceptance as a volunteer, and that unsatisfactory results, refusal to cooperate, or any attempt to affect the results of these background checks will result in me being removed as a volunteer or volunteer applicant.

7.Release of A Heart's Key Communal Care Alliance: Volunteer acknowledges that the Volunteer Activities include a diverse range of activities that could result in harm or injury to Volunteer, whether physical or mental, loss or damage to Volunteer’s personal property, or Volunteer’s death. Volunteer, on behalf of himself/herself and anyone who obtains any rights from Volunteer, hereby forever releases and discharges A Heart's Key Communal Care Alliance and/or its parents, subsidiaries, affiliates, directors, officers, employees, agents, partners, administrators, volunteers, insurers, or successors, or the assigns of any of the foregoing (each a “Releasee”), from, and agrees not to sue any of the Releasees for, any kind of liability, claims, demands, losses, damages, costs, or expenses (including, without limitation, attorney’s fees and costs) arising out of or in any way related to Volunteer’s participation in the Event and related activities, including without limitation the Volunteer Activities.

In addition, volunteer hereby release, and agree that volunteer, their successors, assignees, heirs, guardians and legal representatives will not make any claims or take any legal actions against, A Heart's Key Communal Care Alliance or any of its affiliated organizations, or its officers, directors, employees, agents, or volunteers (“Released Parties”), for my injury, death, damage or loss, however caused, arising from or in connection with my participation in A Heart's Key Communal Care Alliance activities, with the exception of my injury, death, damage or loss as the direct result of illegal or grossly negligent acts by A Heart's Key Communal Care Alliance, and volunteer will hold the Released Parties harmless from any costs or loss, including attorney fees and court costs, arising from or in connection with my activities in violation of these provisions.

8.References. In consideration of the receipt and evaluation of this Application, volunteer hereby authorize you to contact any references, groups, schools attended, former and present employers, charities, courts, and any other person, agency, or organization that may have information about me, and for them to provide to you such information (including opinions) that they may have regarding my character and fitness for working with vulnerable populations; volunteer hereby release any such references, groups, schools attended, former and present employers, charities, courts, and any other person, agency, or organization who may have provided information about me, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. volunteer also agree to hold A Heart's Key Communal Care Alliance Leadership, and any other person to whom the release above applies, harmless from any damages, specifically including attorney fees and court costs, created by or relating to my unwarranted attempt to collect damages for providing information described above or any other unwarranted action by me in connection with this Application.volunteer waives any right that volunteer may have to inspect any information provided about me or by any person or organization identified by me in the Application process.

9. Governing Law. This Release shall be governed by and construed in accordance with the laws of the State of Indiana.

10.Signatures. Volunteer agrees that they are at least 18 years of age.
I hereby certify that all of the information provided by me in this Application (or in any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in these documents may (or will) be cause for the denial of acceptance as a volunteer, or immediate removal as a volunteer, regardless of the timing or circumstances of discovery.

I have carefully read the above Application and this Acknowledgement and Release and know and understand its contents; I also know the above is legally binding on me. I sign this Application and Release of my own free will. By signing this Acknowledgement, Release, and Waiver, Volunteer and Volunteer’s parent or legal guardian, if applicable, acknowledge that he/she/they have read, understand, and voluntarily agree to its terms.
Volunteer Name: (please print)
Volunteer's Signature

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VOLUNTEER APPLICATION

Background

VOLUNTEER APPLICATION

Personal References* (required for first time volunteers only)

VOLUNTEER ACKNOWLEDGEMENT, RELEASE, AND WAIVER

Acknowledgement, Release, and Waiver