Volunteer Application Form Applicant Type(Required) Volunteer Community Service WSU UI Probation- Save Record of hours for 2 years * All volunteer and community service hours are deleted after one year unless you check “Probation/Save Record of hours for two years”.Name(Required) First Last Phone(Required)Email(Required) Gender(Required) Male Female Birth Date(Required) MM slash DD slash YYYY Is there any work you cannot perform?(Required) Have you ever been convicted of a felony or serious misdemeanor?(Required) Yes No If yes, please explain (include dates)(Required)Issue Leading to Arrest:(Required) Drugs Alcohol Sexual Violence Other Please Explain(Required) Please Read and Acknowledge(Required) I certify that the facts above are true and complete to the best of my knowledge and understand that falsified statements shall be grounds for dismissal. I release all parties from all liability for any damage that may result from the information here. Photo Release(Required) I understand that photos (individual and group) may be taken and I give permission for my picture and/or my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, etc.). All photos and copyrights belong to HOPE Center. Medical Release(Required) I authorize treatment by a licensed medical physician or licensed medical team in case of an accident or illness on HOPE Center property. I would like to be notified before the hospital personnel do any additional treatment. I understand that any expense incurred will be my responsibility Emergency(Required) In the event of an emergency or non-emergency situation requiring medical treatment, I hereby grant permission for any and all medical and/or dental attention to be administered to myself. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Emergency Contact Person First Last PhoneFamily Physician First Last PhoneConsent & Liability Waiver(Required) I agree to release The HOPE Center, its officers, agents, employees, volunteers, consultants, and all sponsors and/or officials and staff of any said entity or person, their representatives, agents, affiliates, directors, servants, volunteers, and employees (hereinafter referred to collectively as “Parties Released”) from the cost of any medical care that I receive while volunteering or as a result of it. I further agree to waive, release, and discharge the Parties Released from any and all liability, claims, demands, actions, and causes of action whatsoever, for any loss, claim, damage, injury, illness, attorney’s fees or harm of any kind or nature to me arising out of any and all activities associated with volunteering or as a result of it. Are you filling out this form on behalf of a minor?(Required) Yes No Consent for Minors(Required) I grant permission for my child/children, to participate in activities/duties with Hope Center and/or HOPE Center. I agree on behalf of myself, my child’s other parent if known or living, my child named herein, or our heirs, successors, and assigns, to defend the HOPE Center or any representatives associated with activities/duties. I consent to all of the items listed above under the Confidentiality, Photo Release, Medical Release and Consent & Liability sections above for my child named here. Child/Children name(s)(Required) Code of Conduct as a condition of providing services to the HOPE Center. Work your shift as scheduled or call to inform management of unavailability. Dress is modest business/casual work clothes. No Yoga/Stretch Pants. No open toed shoes. No graphics or logos referring to drugs and alcohol or are violent or sexual in nature. Vests and name tags are provided and required when working. Upon arrival for your shift, clock in. Clock out for lunchtime. No consumption of food or drink other than breaks and lunch times. Lockers are provided for personal use. Bring your own lock. No shopping during your shift. Before, after, and breaks are fine. 20% discount is given to all workers. Items cannot be taken without payment (stealing) or for personal gain (scamming). Workers are not allowed to make deals with friends or customers. Send them to management. Conduct yourself in an appropriate manner, polite and courteous. Treat customers, staff, and other volunteers with respect and consideration. Harassment, sexual or related to race, religion, gender, national origin, medical conditions, or sexual orientation will not be tolerated. No cell phones or music player use while on shift. Request special permission for necessary phone calls from managers. Keep the number of personal visitors to a minimum during your shift. Possession of or being under the influence of alcohol or an illegal drug is prohibited. We retain the right to random drug testing. Tobacco products are permitted only in the designated area. Weapons, including pocket knives, are not allowed on the premises. Use of profanity is prohibited. Failure to comply with the Code of Conduct is grounds for removal. Signature(Required) First Last Date(Required) MM slash DD slash YYYY Δ
