Volunteer Application - The Arc of East Central Iowa

Name *

Address *

Country

City

State

Zip code

Phone *

Email *

Emergency Contact *

Emergency Contact Phone *

Have you ever been convicted of a felony? *

Yes

Please Explain *

Do you have a conflict with our agency conducting a background check on you? *

Yes

Background check instructions

The Arc of East Central Iowa requires a background check for all volunteers.

Occupation – Current or before retirement *

Education and Training Background *

Special Skills or Talent *

Do you have experience working with individuals with disabilities? *

Yes

Please provide details of your experience *

Do you require work accommodations to volunteer at The Arc? *

Yes

Please indicate your need *

How did you hear about The Arc?

Age you prefer to volunteer with? *

Children

Youth

Adults

Summarize your previous volunteer experience *

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. In addition, by submitting this application, I fully understand that when I provide volunteer services for The Arc of East Central Iowa, I will hold The Arc harmless for any injury or property damage that arises out of the provision of such services and it is further understood that The Arc waives all responsibility in the event of an injury or property damage caused by a volunteer while providing volunteer services. Finally, I understand that any photograph taken during a volunteer service may be used by The Arc of East Central Iowa for any legal purpose deemed appropriate by The Arc.

I acknowledge my agreement

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Date *

Our Policy

It is the policy of The Arc to provide equal opportunities without regard to race, color, gender, age, sexual orientation, gender identity, religion, creed, national origin or ancestry, citizenship, physical or mental disability, pregnancy or related medical conditions, other medical conditions, genetic tests/information or characteristics, veteran or military status, marital or familial status, political affiliation, or any other factor protected by law.

Agreements

Please acknowledge your agreement with all the polices and sign at the bottom.

Volunteer Confidentiality Agreement

The Arc of East Central Iowa is legally bound to abide by the Health Insurance Portability and Accountability Act (HIPAA). In addition, The Arc is ethically obligated to abide by Federal and State Confidentiality Laws. Any individual who volunteers with The Arc of East Central Iowa is responsible for maintaining the confidentiality of both the consumers and employees of the agency throughout the duration of their volunteer time and following separation from The Arc. All information concerning a consumer and his/her family as well as an employee of The Arc is confidential and should not be shared with anyone other than Arc supervisory staff or a relief staff with a specific need to know. This includes, but is not limited to, sharing information about one family with another family, having consumer or employee documents where others can see them, or indicating that a family receives services through The Arc. The very fact that an individual is served or an individual is an employee must be kept private and confidential. It is important to note that a consumer’s or employee’s right to confidentiality is not absolute if one or more of the following criteria are established: the individual poses an immediate danger to themselves or to another designated individual. The Arc requires that all volunteers sign this Confidentiality Statement as a condition of their volunteer status. Should an occasion arise in which the volunteer is unsure of obligations under this policy, it is their responsibility to consult with the person who is supervising their volunteer experience.

I acknowledge that I have read and understand the above information regarding consumer and employee confidentiality. I agree to adhere to the HIPPA and Confidentiality requirements of The Arc of ECI both during and upon completion of my time. *

Volunteer Statements

I (select one) have a conviction of any law in any state or any record of founded child abuse or dependent adult abuse in any state. *

do not

Please briefly explain the circumstances. The director will discuss any affirmative responses with you. *

I, (select one) have any communicable diseases or health concerns that would pose a threat to the health, safety, or well-being of the children *

do not

Name *

I declare the above statement to be true

Signature

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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

I understand that, prior to my employment, it will be necessary for The Arc of East Central Iowa to investigate my driving record. I hereby give consent for The Arc of East Central Iowa to contact the Linn County Clerk of Court office and for that office to release to The Arc of East Central Iowa any information they have regarding my record.

Today's Date

Name *

Names previously known as

Date of birth *

Home Address *

Country

City

State

Zip code

Signature

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