Volunteer Application

Personal Information

First Name *

Middle Name *

Last Name *

Birthdate *

Home Address *

Apt.#

Home Phone *

City *

ST *

Zip *

County *

Email *

Cell Phone *

Social Security Number *

Sex *

Ethnicity *

Marital Status *

Highest Level of Education *

Employer: *

Occupation: *

May we contact you at work? *

yes

Employer Address: *

How long employed? *

Work hours/week: *

Work Phone *

Possession of a driver's license is a requirement to participate as a volunteer in our programs to transport a youth in any vehicle you are operating.

Do you have a valid driver's license? *

yes

State of issue and license number: *

Expiration Date: *

Do you have a criminal record? *

yes

If "yes" was selected on previous question, please provide the particulars (offense, date, location, circumstance & outcome) of such record:

References

Please provide any other addresses you've had in the past three years.

Most recent address prior to your current one:

Date at this address:

Prior Address:

Date at this address:

Prior Address:

Date at this address:

Prior Address:

Date at this address:

Please list four (4) references who have known you longer than one year and preferably observed you with children. Please clearly print their name, telephone numbers (daytime, cell, etc), email and relationship to you. Do not include more than one family member.

1. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

2. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

3. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

4. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

Additional Personal Information

Have you ever applied to be, or been a mentor or volunteer with children/youth? * 🛈

yes...when & where? yes...when & where?

What, if any, other youth organizations have you worked for or been involved with as a volunteer?

How did you hear about our program?

List other groups or associations you're involved with:

Do you speak any other languages or have any special skills?

I understand that:

1. The references I listed may be contacted by mail, email or telephone;

2. I am in no way obligated to perform any volunteer services;

3. The information I provided may be used to conduct a background check, to include driving records check, criminal background check, and other records where required by local, state or federal law for volunteers working with youth;

4. Amachi Central KY, Urban Impact and/or Read to Succeed is not obligated to match me with a youth; I understand that Amachi Central KY, Urban Impact and/or Read to Succeed is not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

5. Other youth organizations where I have worked or volunteered may be contacted as references; and,

6. As part of the enrollment process, I will be asked to provide additional personal information prior to any recommendations for assignment (such as a valid driver's license or ID and proof of auto insurance).

By signing below, I attest to the truthfulness of all information listed on this application and agree to the above terms and conditions.

Applicant Signature *

clear

date *

Confidentiality Policy

Amachi Central KY and Urban Impact respect the confidentiality of client and volunteer records and, with the exception of situations listed below, shares information about clients and volunteers only among the agency professional staff.

All records are considered the property of the agency and not the agency workers or clients or volunteers themselves. Records are not available for review by the clients or volunteers.

1. Information will be released to other individuals or non-Amachi Central KY and Urban Impact organizations only with the client or volunteer's written consent.

2. Identifying information regarding clients and volunteers may be used in agency publications or promotional materials unless the clients or volunteers request otherwise.

3. Member of the Board of Directors or evaluators appointed by the Board have access to client files upon authorization of the Board of Directors.

4. Information shall only be provided to law enforcement officials or to the courts pursuant to a valid and enforceable subpoena.

5. Information shall be provided to an agency's legal counsel in the event litigation or potential litigation involving the agency.

6. State law mandates that suspected child abuse be reported to the Kentucky Department for Health & Human Services.

7. If an agency worker receives information indicating that a client or volunteer may be dangerous to himself or herself or others, necessary steps may be taken to protect the appropriate party. This may include a medical referral or report to the local law enforcement authorities.

8. At the time a child or volunteer is considered as a match candidate, information is shared between the prospective match parties. The information about the volunteer may include such items as: age, sex, race, religion, interests, hobbies, marriage/family status, sexual orientation, living situation, etc. Information about the child may include such items as: age, sex, race, religion, interests, hobbies, family situation, etc.

I agree to program participation under the above conditions. I further agree that I will not share identifying confidential information with anyone outside the agency, including family, friends, or community members, without the written consent of the persons involved (parent/guardian of the client or youth volunteer, or the adult volunteer). I also acknowledge that such information should be shared judiciously even within the ranks of Amachi Central KY and Urban Impact only with persons who have a specific need to know the information, and only in situations where others would not overhear such communication.

Volunteer Applicant Signature *

clear

Date: *

Witness Signature *

clear

Date: *

Permission and Release of Liability for Volunteer Participation

I accept liability to participate in programs conducted by Lexington Leadership Foundation, including Amachi and/or Urban Impact. I understand that Lexington Leadership Foundation is not obligated to match me with a child in a mentoring program and that, as part of the enrollment process, I might be asked to provide additional personal information. If I am matched with a mentor and/or reader, or afterschool and/or summer program, I agree to support my match and participation and to immediately report any concerns I might have to the Amachi and/or UI staff.

I understand that although the activities will be supervised by staff and approved volunteers, I do assume the risk for my participation in the program. Participation in any specific activity is always voluntary for students and volunteers.

I acknowledge that I will not seek to hold Lexington Leadership Foundation liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of participation in this program. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from my participation. I hereby release and agree to hold harmless Lexington Leadership Foundation, its officials, agents and employees, from any claims arising out of my participation in the program. I have read and understand and accept all of the statements above and accept full responsibility as described.

Volunteer Applicant Signature *

clear

Date: *

Application Disclosure & Release

Read and complete the following:

1. In connection with my application for volunteer work, I understand that an investigative criminal, sex-offender and motor vehicle report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination from past employment. I understand that as directed by company policy and consistent with the position described, you may be requesting information from public and private sources about my: driving record, credentials, criminal history records and references.

2. I acknowledge that a telephone facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies.

3. By my signature below, I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, and school, employer, reference or insurance company contacted by Lexington Leadership Foundation to furnish the information described in Section 1.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Please provide your full name: *

Please list other names you have used (maiden, aliases, etc) *

Dates used: *

Present Address: *

How long at this address? *

City, ST, Zip *

Second Prior Address: *

County *

City, ST Zip *

How long at this address? *

Amachi Central KY and Urban Impact Statement of Agreement

Amachi Central KY and Urban Impact appreciate your interest in becoming a volunteer.

Please initial each of the following:

I agree to follow all mentoring, after school and/or reading program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. *

I understand that my photo may be used in Amachi and Urban Impact publicity and I grant such permission. *

I will provide a valid photocopy of my driver’s license or ID and current auto insurance card. *

Volunteer Applicant Signature *

clear

Date: *

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