• Bittersweet Farms Volunteer Application

    Please complete this form to apply as a volunteer. All information will be kept confidential.

  • Personal Information

  • Format: (000) 000-0000.

  • Legal Parent / Guardian Information (if applicant is a minor)

  • Format: (000) 000-0000.

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Background Information

    (Please note, a background check will be performed on all Bittersweet Farms volunteers.)
  • Have you ever pled guilty or “no contest” to a crime or been convicted of a crime (felony or misdemeanor)? Please select one:*
  • Do you have any criminal charges pending? Please select one:*

  • Volunteer Information

  • After given instruction, you must be able to perform any duties assigned independently or provide your own
    support. Duties include, but are not limited to, heavy lifting, weeding, trimming, replanting, packaging,
    cleaning, baking, and organizing. Volunteers will be expected to be on their feet for long periods of time
    and must be comfortable working in all weather conditions.

  • Have you ever worked with individuals with Autism/DD?*
  • Please select the location(s) at which you would like to volunteer:*
  • Please select the frequency with which you would like to volunteer:*
  • Please select what days you are available to volunteer:*
  • Please select which shift you would prefer to volunteer:*
  • Are you able to perform the above duties & other duties as assigned independently?*

  • Additional Requirements

  • Are you fulfilling a school/court/diversion program requirement?*

  • If yes, please complete the following information:

  • Contact information for School/Court/Diversion Program:

  • Notice of Background Checks to Volunteers (Adult Volunteers Only)

  • I agree to submit to and authorize Bittersweet, Inc. to conduct verification checks of my criminal background, personal and professional references, and searches of other public and private records as Bittersweet, Inc. deems necessary to secure information regarding me as a volunteer for the capacity I am seeking.

    Bittersweet, Inc. reserves the right to review the following information prior to allowing volunteers to work with or alongside our participants: Nurses Aid Registry Record, Abuse Registry Record, Sex Offender Database, Offender Database from Department of Rehabilitation and Corrections, System for Award Management (SAM) Database, Inspector General Exclusions and the Medicaid Provider Exclusion and Suspension List.

    Prior to placing a person in a volunteer role, Bittersweet, Inc. requires an applicant to indicate that he/she has NOT been convicted of, pleaded guilty to, or been found eligible for intervention in lieu of conviction, for any of the offenses and/or violations of the Ohio Revised Code.

    I have read the offenses found on the list of violations of the Ohio Revised Code. I have not been convicted of, plead guilty to, or am found eligible for intervention in lieu of conviction to any of the referenced offenses which includes any offense(s) that has been sealed.

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  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • I further understand that I am required to notify the Volunteer Coordinator within 14 days if at any time during the application process or volunteering with Bittersweet, Inc. I am charged with, am convicted of, plead guilty to, or am found eligible for intervention in lieu of conviction for any of the offenses on the attached list of violations of the Ohio Revised Code.

    The information provided on this application is true, correct, and complete.

    I hereby authorize investigation of all statements in this application and request any company, institution, or persons contacted as part of this investigation to provide any and all pertinent information. To assure their cooperation, I hereby release them from all liability for any damage that may result from furnishing same to Bittersweet, Inc.

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Signature Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Consent for Use of Photographs

  • I      *         permission for the use of photographs and/or videos taken of at Bittersweet Farms, Bittersweet Pemberville, and Betty’s Farm.

  • I     permission for the first name only of the individual listed above to be used by Bittersweet, Inc. I understand that the photographs, videos, and/or names may be used for educational and/or promotional/social media purposes. These photographs and videos may also be used on the Bittersweet Website, Bittersweet Facebook Page, media articles, and other social media sites. This permission is granted indefinitely or until Bittersweet, Inc. receives written notification from the volunteer/parent/guardian/participant indicating otherwise.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Waiver and Release of Liability, and Assumption of Risk

  • 1. Is Volunteer a minor?*

  • 2. I agree and understand that as a volunteer, Bittersweet, Inc. is not obligated to provide me or my minor child any payment or benefit for services. I hereby acknowledge that any activity involves the risk of serious injury and/or death and/or property damage. Risks and dangers may arise from foreseeable and unforeseeable causes including but not limited to weather conditions, and such other risks, hazards and dangers that are integral to the services provided by Bittersweet Inc.

    3. I agree to release, waive and discharge Bittersweet, Inc., its Board of Trustees, its entities & affiliates, employees and agents (collectively Bittersweet, Inc.) for and from any and all liability loss or damage, and any claim or demands therefore on account of injury and/or death to me or and/or property damage, now and forever, arising out of or related to participation and/or instruction in any activities that may occur while acting as a volunteer whether caused by the negligence of Bittersweet Inc. or otherwise. I understand and agree that this Waiver and Release of Liability and Assumption of Risk is made on my own behalf and on behalf of our heirs, executors, representatives, assigns and when applicable, our minor child.

    4. I hereby acknowledge that this Waiver and Release of Liability and Assumption of Risk extends to all acts of negligence by Bittersweet Inc., and is intended to be as broad and inclusive as permitted by the laws of Ohio and that if any portion thereof is held valid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

    5. I have read this Waiver and Release of Liability, and Assumption of Risk and I fully understand its terms, understand that I have given up substantial rights by signing it, are aware of its legal consequences, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to us and intend our signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

  • Parent/Guardian Signature Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • **OR**

  • Signature Date of (ADULT) Volunteer
     - -
    2 digit month, 2 digit day, 4 digit year

  • Bittersweet Farms HIPAA & Confidentiality Policy (Adult Volunteers Only)


  • 1. I agree not to disclose or discuss any program participant/resident, human resources, and/or management information with those who are not directly involved with the participants’ care. This includes but is not limited to verbal and written discussion as well as electronic media.

    2. I agree not to access any information or utilize any equipment other than that which is required to do my job.

    3. I understand that accessing data must not occur simply to satisfy a curiosity, and it is unacceptable to look up data other than that required to perform my job.

    4. I agree not to discuss resident/participant, human resources, or administrative information where others can overhear, i.e. public areas of the farm, in restaurants and other public places and social events. This includes, but is not limited to, verbal and written discussion as well as electronic media.

    5. I understand that it is not acceptable to discuss participant information in public areas even if a participant’s name is not used. This could raise doubts with participants, guardians, and other providers about our respect for a participant’s privacy. This includes, but is not limited to, verbal and written discussion as well as electronic media.

    6. I agree not to make inquiries for other personnel who do not have proper authority.

    7. I agree not to willingly inform another person of my computer password or knowingly use another person’s computer password.

    8. I understand that my passwords should not be written and placed in an area where others can find them.

    9. I understand that I must not log on to a computer and allow another person to use a computer I have logged on to. If I cannot be at my computer at all times, I will password protect my access to prevent unauthorized use.

    10. I agree not to make unauthorized transmissions, inquiries, modifications, or purging of data in my employer’s computer system. Such unauthorized transmissions include, but are not limited to, removing or transferring data from the employer’s system to another location, i.e. my home computer.

    11. I agree not to load software or programs onto a computer without authorization.

    12. I will not visit any website and transmit any information to or from a site that does not relate directly to my job duties.

    13. I agree to log off prior to leaving at the end of my shift.

    14. I agree to keep papers with protected health information in a secure place. I will promptly remove them from unsecure places such as copiers, fax machines, bulletin boards, and community areas.

    15. I will shred all confidential materials that no longer need to be retained.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Acknowledgement Receipt of Orientation PowerPoint Presentation

  • PowerPoint Orientation Presentation

  • I hereby acknowledge that I have received and reviewed the PowerPoint orientation presentation provided by Bittersweet Farms. I acknowledge that the presentation addressed the history of Bittersweet Farms, Core Values, Philosophy, MAPS, Programs, The Rights of Ohioans with Disabilities, and Tips for Successful Interactions.*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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