Read to Success Volunteer Application

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Are you at least 18 years of age?*

Yes
No

Emergency Contact - name, relationship & phone number*

Reference #1 - Name, relationship, phone number & years known*

Reference #2 - Name, relationship, phone number & years known*

Availability

If there are extended periods of time you already know you will be unavailable, please list them.

Equal Opportunity*

Great Rivers United Way will provide equal opportunities to all individual volunteers and care receivers regardless of their race, age, sex, sexual orientation, creed or religion, color, handicap or disability, marital, citizenship, or veteran status, membership in the National Guard, state defense force, or reserves, national origin or ancestry, arrest or conviction record, or any other characteristic protected by law. This policy applies to our decisions related to the volunteer and care receiver application process and the services and care provided through our programs.

I have read and understand this statement.

Risk Management*

Great Rivers United Way strives to provide a safe, quality volunteer experience for all applicants. Great Rivers United Way will communicate the needs of clients to volunteers in advance of assignments. Volunteers are asked to apply common sense and not undertake services that are unsafe or beyond reasonable expectations for a volunteer assignment.

I have read and understand this statement.

Confidentiality Agreement*

Confidentiality is the legal right to privacy. Any information regarding a client learned through conversations or contained in a student’s file is confidential information. No information should be released to anyone (including family members) without proper authorization. This is a violation of state and federal law. Anyone who discloses information without a current, signed, authorization form can be held liable for damages or it could be grounds for defamation or an invasion of privacy allegations. Both volunteers and Great Rivers United Way can be held liable, but as a volunteer you can also be held liable for civil and criminal penalty. This can include criminal charges, fines and/or jail time. Any volunteer that violates the confidentiality of any client will be terminated from volunteering at Great Rivers United Way. Volunteers are required to respect the privacy of all clients and follow the guidelines of confidentiality. 1. Names of students are not to be mentioned in social settings or outside of normal day-to-day business operations of Great Rivers United Way. 2. Situations that would cause another person to know the student are not to be discussed with anyone except Great Rivers United Way staff. 3. Signs of abuse that is either suspected or observed should be reported immediately to Great Rivers United Way staff.

I have read and understand this statement.

At Will Volunteer*

Although Great Rivers United Way hopes that the volunteer employment relationship with all of its volunteers is a long-term relationship, it is an AT WILL VOLUNTEER relationship. That is, either the volunteer or Great Rivers United Way may terminate the relationship at any time, for any reason, with or without cause.

I have read and understand this statement.

Background Information Disclosure*

You will be asked to complete a background check before you are able to volunteer with Read to Success. All information you provide will go directly through a secure volunteer website. Answering affirmatively to any questions will not necessarily bar you from volunteering with this program. However, failure to comply or providing false information may result in denial. The information given in this application is correct and accurate to the best of my knowledge. I have reviewed all of my responses before forwarding this document to Great Rivers United Way. I acknowledge that knowingly providing false information or omitting information will result in denial or termination of volunteer activities and other penalties as provided under the law. Further, I understand and agree that as a part of the Great Rivers United Way enrollment process, agency personnel will obtain information about me from references, public records, interviews and other sources as deemed necessary for program participation. By signing this application, I hereby release and indemnify Great Rivers United Way, its officers, board of directors, staff and participants from and against any and all claims and liability for negligence, willful misconduct, or sexual abuse relating to my participation in this program.

I have read and understand this

Signature*

Please type your full, legal name.

Today's Date*

Open Your Heart.

Lend Your Muscle.

Join The Movement.