Volunteer Application Form

Transcription

1 Volunteer Application Form Volunteer Full Name: Phone Number: Supervisor s Name: Office/ Department: Program: Phone Number: Volunteer Dates: Start Date: End Date: Type of Volunteers: Camps and Programs for Minor Volunteer Student Volunteer Community Volunteer Fellows Documentation Needed for Volunteers: All Volunteers o Background Check with BC DPS Form o Required Trainings for Non-Employees Depending on Type o Staff and Volunteer Contract o Model Release for Minors/ Model Release for Adults o Waiver, Indemnification, Assumption of Risk and Medical Treatment Authorization o System Volunteer Waiver Form TAMIU Student Volunteer o Contact Office of Student Affairs in addition to submitting paperwork with CE. Office of Continuing Education Student Center 118~ Phone: ~ Fax: ~ ce@tamiu.edu Updated: 9/02/2015 SJJ

2 A Member of The Texas A&M University System Office of Human Resources VOLUNTEER WAIVER FORM With few exceptions, you have the right to request, receive, review, and correct information about yourself collected using this form. I certify that I am offering my services to Texas A&M International University (TAMIU) on a volunteer basis and understand that I will receive no pay, benefits, or other privileges of employment of any kind for my services. I further understand that I am not eligible for worker s compensation benefits if I am injured or become ill as a result of my volunteer work, nor am I eligible for unemployment compensation benefits when my volunteer assignment ends. I have not been promised and have no expectation that I will receive a paid position as a result of my volunteer work. I understand that all volunteers must undergo a criminal background history check. Once volunteering, I understand I must report any criminal arrests, criminal charges, or criminal convictions (excluding misdemeanor traffic offenses punishable only by fine) to my supervisor within 24 hours or at the earliest possible opportunity thereafter. I certify that I am: (check one) under 18 years of age and have parent or guardian consent to provide my volunteer services at TAMIU. not employed by the State of Texas, TAMIU, or any other public entity, and I am performing the proposed volunteer work for civic, charitable, or humanitarian reasons. an employee of the State of Texas or TAMIU. The proposed volunteer work is in a different occupational capacity from that in which I am employed, and I am performing the volunteer work for civic, charitable, or humanitarian reasons. Printed Name of Volunteer Signature of Volunteer Date Printed Name of Parent or Guardian Signature of Parent or Guardian Date (if volunteer is under 18 years of age) (if volunteer is under 18 years of age) Signature of Witness Date Emergency Contact Information: Name Home Number Cell Number 5201 University Boulevard, Killam Library Building, Room 320, Laredo, TX U.S.A. (956) FAX (956)

3 WAIVER, INDEMNIFICATION, AND MEDICALTREATMENT AUTHORIZATION FORM 1. EXCULPATORY CLAUSE. In consideration for receiving permission to participate in any and all activities of ( activity ), which is sponsored by ( sponsor ), a member of The Texas A&M University System, I hereby release, waive, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, The Texas A&M University System, the Board of Regents for The Texas A&M University System, and their members, officers, agents, volunteers, or employees ( RELEASEES or INDEMNITEES ) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney s fees and expenses, that may be sustained by me while participating in this activity, while traveling to and from the activity, or while on the premises owned, leased, or controlled by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. 2. INDEMNITY CLAUSE. I am fully aware that there are inherent risks to myself and others involved with this activity, including but not limited to DEATH, and I choose to voluntarily participate in this activity with full knowledge that the activity may be hazardous to me and my property, and to the person and property of others. I acknowledge there may be physically strenuous activities. I know of no medical reason why I should not participate. I agree to indemnify and hold harmless INDEMNITEES from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney s fees and expenses, which may occur to myself, other participants, and third-persons as a result of my participation and conduct in this activity, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of INDEMNITEES. 3. NO INSURANCE. I understand that RELEASEES do not maintain any insurance policy covering any circumstance arising from my participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. Sponsor does not carry general liability insurance to cover claims arising from this activity so it seeks a waiver of claims as additional consideration for the right to participate so sponsor, a governmental unit of the State of Texas, can (a) provide the activity at the lowest possible cost to participants; and (b) provide access to a greater number of participants by expending limited resources on program materials rather than on liability insurance. 4. BINDS HEIRS. It is my express intent that this agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Texas. 5. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand RELEASEES cannot be expected to control all of the risks associated with this activity and RELEASEES may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical facility, during my participation in this activity with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless INDEMNITEES for any costs incurred to treat me, even if an INDEMNITEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, covenant not to sue, and agree to hold harmless for any and all purposes, RELEASEES from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney s fees and expenses, that may be sustained by me while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. Page 1 of 2

4 6. VOLUNTARY SIGNATURE. In signing this agreement I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; sponsor has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future. For students engaging in extracurricular activities: I understand I can choose not to sign this document and free myself from its terms and the associated risks of the activity by simply not participating in the activity and choosing some other activity available to me that has a lower level of risk to me. I further understand this is a voluntary, extracurricular activity; therefore it is not required for me to obtain college credits and not participating in this activity will in no way hinder my ability to obtain a degree from the university. For students going on fieldtrips or other class-related activities: I understand participation in this class/fieldtrip/activity is not mandatory and I will not be penalized for failing to participate in this activity because an alternative activity exists for which I can receive like credit. While I understand alternative activities are available to me that do not have the risks associated with this activity I still desire to voluntarily engage in this activity. SIGNING THIS DOCUMENT INVOLVES THE WAIVER OF VALUABLE LEGAL RIGHTS. CONSULT YOUR ATTORNEY BEFORE SIGNING THIS DOCUMENT. SIGNED this day of, 20 _. Participant Signature: Printed Name: Participant s Date of Birth: Parent or Legal Guardian Signature: (If Participant is under 18 years old) Parent or Legal Guardian Printed Name: (If Participant is under 18 years old) INSTRUCTIONS: (1) The document should be printed in a font size no smaller than 10-point type. This is 10- point type. This is 12-point type. (2) The formatting/font style (bolded, underlined, and italicized) in paragraph nos. 1, 2, 5 & 6 should not be altered. TAMUS-OGC-Approved 5/7/2015 Page 2 of 2

5 Texas A&M International University MODEL RELEASE In consideration of my engagement as a model, and for other good and valuable consideration herein acknowledged as received, I hereby grant to Texas A&M International University and those acting with the University s authority and permission, the irrevocable and unrestricted right and permission to copyright in TAMIU s own name or otherwise, ad use, re-use, publish, and re-publish photographic or distorted in portraits or pictures of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions, therefor in color or otherwise, made through any medium at University studios or elsewhere, and in any and all media now or hereby known for illustration, promotion, art advertising trade, or any other purpose whatsoever. I also consent to the use of any printed or electronic matter in conduction therewith. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless Texas A&M International University (TAMIU), the University s legal representatives and assigns, and all persons acting under University permission nor authority or those for whom they are acting, for an liability by virtue or any blurring, distortion, alteration, optical illusion, or use in composite form, whether international or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing therefor, as well as any publications, theory, including without limitation any claims for libel or invasion of privacy. I hereby warrant that I am of full age and have height to contract in my own name. I have read the above authorization, release, and agreement, prior to its execution and I am fully familiar with the contents thereof. This release shall be biding upon me and my heirs, legal representatives, and assigns. MODEL Name (Print): MODEL Name (Print): Address: City/State/Zip Code: Signature: Date: WITNESS Name (Print): Address: City/State/Zip Code: Signature: Date: Revised 3/14/2017 MDLG

6 Texas A&M International University TM MODEL RELEASE FOR MINORS In consideration of my engagement as a model, and for other good and valuable consideration herein acknowledged as received, I hereby grant to Texas A&M International University and those acting with the University's authority and permission, the irrevocable and unrestricted right and permission to copyright, in TAMIU's own name or otherwise, and use, re-use, publish, and re-publish photographic or electronic portraits or pictures of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions, thereof in color or otherwise, made through any medium at University studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art advertising trade, or any other purpose whatsoever. I also consent to the use of any printed or electronic matter in conjuction therewith. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless Texas A&M International University (TAMIU), the University's legal representatives and assigns, and all persons acting under University permission or authority or those for whom they are acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publications, thereof, including without limitation any claims for libel or invasion of privacy. I hereby certify that I am the parent and/or guardian of, a minor under the age of 18 years, and I hereby consent that any photographs which have been, or are about to be taken by Texas A&M International University, may be used by the University for the purpose set forth in the above authorization, signed by the minor model, with the same force and effect as if executed by me. I have read the authorization, release, and agreement, prior to its execution and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. MODEL Name (Print): Signature: Date: PARENT AND/OR GUARDIAN Name (Print): Address: City: State: Zip: Phone: Signature: Date: WITNESS Name (Print): Address: City: State: Zip: Phone: Signature: Date: Revised 6/29/2011

7 Texas A&M International University Background Check Authorization Form With few exceptions, you have the right to request, receive, review, and correct information about yourself using this form. A Member of the Texas A&M University System An Equal Opportunity/Affirmative Action/Veterans/Disability Employer: Texas A&M International University does not discriminate on any basis prohibited by applicable law including race, color, religion, sex, national origin, disability, age, citizenship status, or veteran status in recruitment, employment, promotion, compensation, benefits, or training. The information on this form is the property of Texas A&M International University. The following is to be completed by the hiring department: Job Vacancy Number: Title of Position: Department: Requested by: Department Paying Account to be Charged (investigation involves a minimal fee of approximately $5): The following is to be completed and signed by the applicant/employee: Please legibly print all information requested. Last Name: First Name: Middle Initial: SSN: Please indicate other name(s) used in any and all other records of birth or records of residence. Present Address (number and street) City State Zip Code Race: Sex: DOB (mo/day/yr): Driver s License #: State Issuing Driver s License: The following are my responses to questions about my criminal history, if any (excluding minor traffic offenses). Circle Yes or No. 1. Have you ever been convicted or pled guilty before a court for any federal, state, or municipal criminal offense? Yes No 2. Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal offense? Yes No 3. Have you ever received pretrial diversion or similar disposition for any federal, state, or municipal offense? Yes No 4. Have you ever received probation or community supervision for any federal, state, or municipal offense? Yes No 5. Have you been convicted of any criminal offense in a country outside the jurisdiction of the United States? Yes No 6. As of the date of this consent form, do you have any pending charges against you? Yes No If you answered Yes to any of the questions above, please provide details below. Attach extra pages if needed. State: County: Date of Offense (mo/day/yr): Details of Offense: State: County: Date of Offense (mo/day/yr): Details of Offense: Please list all places of residence since the age of 18. Include city, state, county, and country. Attach extra pages if needed. I hereby authorize Texas A&M International University (TAMIU) to obtain my criminal history record. TAMIU may obtain my background information, including criminal history record, Selective Service registration, and degree verification at any time during my application process and/or employment. I understand this information will be used for the purpose of determining my eligibility for employment or continued employment with TAMIU. I hereby authorize the Texas Department of Public Safety or any other entity authorized to access state or federal agency records to furnish TAMIU, or its agent, my criminal history record. I do hereby release all agents, servants, and employees of TAMIU; the person in charge of any law enforcement agency or department; and all members of such law enforcement agency or department from all liability resulting from the release of this information. I acknowledge that a facsimile or copy of this document shall have the same validity, force and effect as the original. System Regulation addresses the operation of criminal history investigations within the A&M System, including appeal procedures, and requires that within 24 hours or at the earliest possible opportunity, an employee must report to his/her supervisor any criminal arrests, charges, or convictions, excluding misdemeanor traffic offenses punishable only by fine. Failure to report shall constitute grounds for disciplinary action, up to and including dismissal. The employee s supervisor must report the criminal arrest(s), charge(s), or conviction(s) to both the head of the department/unit and the Human Resources Office. I hereby certify that all information provided by me on this form is true, complete, and correct. I understand that any false statements made herein may void my application for employment, be grounds for termination of my current employment, and affect my eligibility for future employment with Texas A&M International University. Printed Name of Applicant/Employee Signature of Applicant/Employee Date HR FORM; Revised 12/19/12

8 DPS Computerized Criminal History (CCH) Verification (AGENCY COPY) I,, have been notified that a Computerized Criminal APPLICANT or EMPLOYEE NAME (Please print) History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply. Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services. Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me. (This copy must remain on file by your agency. Required for future DPS Audits) Signature of Applicant or Employee Date Agency Name (Please print) Agency Representative Name (Please print) Please: Check and Initial each Applicable Space CCH Report Printed: YES NO initial Purpose of CCH: Volunteer Hire Not Hired initial Signature of Agency Representative Date Printed: Destroyed Date: initial initial Date Retain in your files Rev. 02/2011

9 Programs and Activities Serving Minors Program/Activity Staff Code of Conduct This Code of Conduct applies to all Program/Activity Staff ( Staff ), which includes volunteers, working with minors in a University program or activity. Along with any Program/Activity-specific guidelines and procedures, Staff are required to comply with all applicable laws, University policies, and the requirements herein. (1) General Staff should work cooperatively with youth, families, University faculty, other Staff, community members and others in a courteous, respectful manner demonstrating behaviors appropriate for a positive role model. Staff should represent the University and the Program/Activity with pride and dignity, behave appropriately, refrain from using profanity, exhibit good sportsmanship, and demonstrate reasonable conflict management skills. Staff should respect, adhere, and enforce the Participant Code of Conduct as well as other rules, policies and guidelines established by the Program/Activity Administrator, including state laws and regulations. (2) Two Adult Rule Generally, two Staff should always be present with a minor. When it is necessary to speak privately with a minor, meet in open, well-illuminated spaces or rooms within sight of other Staff. (3) Mentoring Programs/Activities that involve mentoring or private instruction (tutoring, laboratory, music lessons, etc.) where there is only one Staff present should take place in a room or other space that is in full view from outside the room even when the door is closed. These Programs/Activities should only take place in authorized facilities, never a private residence. (4) Time and Place Do not meet with minors outside of the established time or place designated for the Program/Activity. (5) Transportation Never transport a minor without parent/guardian permission, and avoid being alone with a minor in a vehicle. All transportation should comply with the University and Program/Activity transportation guidelines and policies. (6) Privacy The privacy of all individuals should be respected in situations such as toileting, showering and changing clothes. When it is necessary to supervise minors, at least two Staff should be present and only to the extent that the health and/or safety requires. (7) Touching Do not touch minors in a manner that a reasonable person could interpret as inappropriate. Always avoid touching areas that are normally covered by swim suits. When hugging is appropriate, hug from the side over the shoulders, not from the front. (8) Overnight When supervising overnight activities, Staff should not share sleeping areas with minors. (9) Sexual Conduct and Communications Engaging in any sexual conduct, making sexual comments, telling sexual jokes, or sharing sexually explicit material (or assisting in any way to provide access to such material) with minors is prohibited. Staff must not engage or allow minors to engage them in romantic or sexual conversations, or related matters. (10) Online Communications Staff should not engage or communicate with minors through , text messages, social networking websites, internet chat rooms, or other forms of social media at any time, except and unless there is an educational or programmatic purpose and the content of the communication is consistent with the mission of the Program/Activity and the University. (11) Other Communications It is inappropriate for Staff to share sensitive personal information about themselves with minors, including information about financial challenges, workplace challenges, drug or alcohol use, promotion of particular religious or political beliefs, and romantic relationships. (12) Discipline Any discipline used should be constructive, not humiliating or isolating. Physical punishment is not an appropriate form of discipline and IS NOT allowed. (13) Photography Photographing minors is prohibited, except for Program/Activity-related purposes where the parent or guardian has executed a Photo and Media Release. Use of any device capable of recording and transmitting visual images in shower areas, restrooms, or other areas where privacy is expected is strictly prohibited. (14) Gifts Staff may not provide gifts to minors independent of items provided by the Program/Activity.

10 (15) Administering Medication Medication must only be administered to a minor in accordance with the parent/guardian s written instructions. Do not provide or administer medication without first consulting the Program/Activity Administrator. (16) Substance Use Prohibited Do not use, possess or be under the influence of alcohol, illegal drugs, or any prescription medication that impairs your ability to perform your duties during the Program/Activity. Do not condone others use of alcohol or illegal drugs during the Program/Activity. Recognize that UGA is a tobacco-free campus and that smoking and tobacco use is prohibited. (17) Non-Discrimination Staff must comply with UGA s Non-Discrimination and Anti-Harassment Policy. Hazing initiations are prohibited and may not be included as part of any Program/Activity. Verbal, physical, and cyber bullying are prohibited. (18) Report Injuries Report any accident, injury or illness of a minor immediately to the Program/Activity Administrator. (19) Mandatory Reporter All Staff are considered mandatory reporters for purposes of the Policy and must report incidents involving sexual or physical abuse or neglect of a minor immediately to the Program/Activity Administrator, the UGA Police Department, AND the Georgia Department of Family and Children Services (DFCS). My signature confirms that I have read and understand this Code of Conduct. My signature further confirms that I agree to abide by this Code of Conduct. Failure to abide by this Code of Conduct may result in disciplinary action or sanctions against me, including but not limited to, removal from the Program/Activity, exclusion from future Programs/Activities, termination, and/or criminal prosecution. Printed Name Signature Date

11 CHILD PROTECTION TRAINING FOR NON EMPLOYEES As per System Regulation , an individual hired or assigned to an employee or volunteer position involving contact with minors at a camp and program for minors is required to complete training and examination on sexual abuse and child molestation. Instructions for External Gateway (Contract or Volunteers) The external gateway is intended for A&M System-affiliated individuals only working member sponsored Campus Programs For Minors. To access the gateway, an individual needs two things: a working address and the current generated password. NOTE: The gateway will send the completion certificate to this address. 1. Go to, 2. Type address where you will receive certificate and the current password. Contact ce@tamiu.edu for the most updated password. Password: Lacquer^CAPrice#03 3. Click Submit. 4. Find the desired course. In this case, Child Protection Training (Approval #PM ). 5. Click Start. 6. The user will be required to enter their name, employer and the How did you hear about this course? fields. It is very important to ensure they enter their first and last name because that is what will appear on the completion certificate. Employer information should be input as TAMIU and Department or PM name. Example: TAMIU- Continuing Education or TAMIU- Elementary Camp They can also enter in their work address, city, state, and phone number, but those are not required in order to view the course. If they fill out those fields, they will appear on the completion certificate as well. 7. Click Save. 8. Click Start Course % is the required score for a certificate 10. Upon successfully completing the course, an will be sent to the address that was used to login to the gateway. The will contain a link to the completion certificate. When they click the link, you ll have the option to download the certificate as a PDF. 11. Forward PDF Certificate to CE@tamiu.edu. Please Note: Please obtain this form for your own records. Form should not be submitted to CE Office. Office of Continuing Education ~ Student Center 118 ~ Phone ~ Fax: ~ ContinuingEducation@tamiu.edu