MasterNICA No______NICANorthside Inter-Community Agency, Inc.

Date ___/____/_____Volunteer Survey Form for MinorsVol No______

All information on the application will be kept confidential and is for NICA's volunteer services and programs only.

GENERAL INFORMATION

Title Mr. Ms.Sex:  Male  Female

First Name:______Middle Name: ______Last Name: ______

Address: ______City ______TX Zip______-_____

Phone #: (_____)______-______Cell # (_____)______-______

E-Mail

Date of Birth: _____/______/______Ethnicity: (Circle) African-American , Anglo, Hispanic, Asian, Other______

Are you a student?  yes  no Name of School

Foreign Language: ______Speak  Read  Write

What church, organization or group are you a member of?

BACKGROUND INFORMATION

How did you hear about NICA?  advertisement  church  school  friend/volunteer  other

Describe any physical handicaps or limitations that would affect your ability to perform certain tasks:

 Hearing  Speaking  Seeing  Mobility  Other:

EMERGENCY CONTACT INFORMATION

In case of emergency, contact:______Relationship:

Address: ______City ______TX Zip______-_____

Phone #: (_____)______-______Cell #: (_____)______-______Work#: (_____)______-______

E-Mail

WAIVER OF LIABILITY AND CONFIDENTIALITY AGREEMENT

I understand that NICA cannot be liable for any injuries or illness that my minor dependent may suffer. I waive any such claim for compensation or liability on the part of NICA beyond what may be freely offered by the representative of NICA in the event of injury or illness.

I fully understand that my minor dependent will have access to information about clients as well as other volunteers and staff members. I understand all information pertaining to clients will be kept confidential. Client files will only be given to those who are authorized and that all files will remain on NICA’s premises except through special permission granted by the Executive Director of NICA. My minor dependent will do his/her best to protect the client’s right to privacy.

I also understand that violating confidentiality and/or disregard of NICA’s policies and procedures will result in termination of my minor dependent’s volunteer services.

Signature of Parent or Guardian ______Date

Printed Name of Parent or Guardian

Printed Name of Child

Management Data\Volunteer Data\Forms\Minor Volunteer Survey Rev 12/29/2011 Printed 09/22/2018