Affirmation and Release of Information
Any applicant found to have been convicted of or having charges pending for a felony or misdemeanor involving a theft, sex offense, child abuse or neglect, or related acts that would pose risks to participants or SOAR Fox Cities, Inc. credibility is not eligible to be a volunteer. I hereby affirm that all of the answers provided on my volunteer application are true. If I have misrepresented any information on this application I will be immediately disqualified.
Further, I hereby authorize SOAR Fox Cities, Inc. and any current or former employer, educational institution, law enforcement organization, state and federal government agency, or other information service bureau that is contacted to investigate my background to determine my fitness as a potential volunteer. In addition, I authorize SOAR Fox Cities, Inc. to share the aforementioned information with vendors, partners, affiliates or clients of SOAR Fox Cities, Inc. if SOAR Fox Cities, Inc. believes the furnishing of such information is necessary.
I am aware of the sensitive and confidential nature of the official documents, reports and other material I can be exposed to in my capacity as SOAR Fox Cities, Inc. volunteer. I will discuss these matters only with those persons directly involved in the case or who will be consulted for their professional knowledge and expertise. I also understand that if for any reason it becomes apparent that my activities are contrary to the policies, goals and/or philosophy of SOAR Fox Cities, Inc.’s programs, and their desire to provide quality services to individuals with developmental disabilities, my services as SOAR Fox Cities, Inc. volunteer will be terminated. I submit the statements on this application are true, complete, and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or can result in dismissal at a later time. I have read the above waiver and release statement and fully understand what rights I am waiving by signing this document. I attest to the fact that I have never been charged or convicted of theft, child abuse including sexual, emotional, or physical; neglect; or any other crime against a child or an individual with developmental disabilities. I attest to the fact that I have been convicted of no other crimes, except as listed.
I hereby authorize, SOAR Fox Cities, Inc. to use, reproduce, and/or publish photographs and/or video that may pertain to myself/my child - including image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on SOAR Fox Cities, Inc.'s website and other social media sites. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, SOAR Fox Cities, Inc. may publish materials, use my name, photograph, and/or make reference to me in any manner that the agency deems appropriate in order to promote/publicize the agency, its programs and participants. I release SOAR Fox Cities, Inc. from any claims, damages or liability which I may ever have in connection with the taking of use of the images or printed material used with the images.
By typing my name in the indicated fields, I hereby certify that all of the information submitted in this form is true, accurate and complete. I understand that transactions and/or signatures in records may not be denied legal effect solely because they are conducted, executed, or prepared in electronic form, and that if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement. I further understand that false statements made knowingly and willfully on this form are punishable by fine and/or imprisonment under the provisions of 16 U.S.C. §1857 and 18 U.S.C. §1001.