Fgp Volunteer Application

Volunteer Application

Please complete this application in its entirety. Only complete applications will be considered.

Today’s Date:______

Applicant’s Name:______

(Please Print) First Last MI (Maiden Name)

Street Address:______City:______TX

Mailing Address:______City:______TX Zip Code:______

Home Phone:______Cell Phone:______

SS#:_____-_____-_____ Birthday:_____/_____/_____ Age:______Birth State:______

Are you a U.S. Citizen: Yes No If “No” are you authorized to work in the U.S.: Yes No

Driver’s License #:______State Issued:______Expiration:_____/_____/_____

Marital Status: Married Single Widowed Divorced

Number of persons living in your household:______

Do you have your own transportation?:______Would you need transportation?:______

Have you ever been a Foster Grandparent? YES NO Where/Year?:______

Education & Work Experience:

Highest Level of School Completed (please circle): 1 2 3 4 5 6 7 8 9 10 11 12 GED

College Associate Degree Bachelor Degree Other

Previous Occupation:______Number of Years in Occupation:______

Job Related Questions: These questions will assist our FGP staff in placing you. They are not intended to disqualify you from the program. Reasonable accommodations may be available.

This Volunteer position may require the following; prolonged sitting, standing, bending/stooping, lifting an infant/small child, climbing stairs, kneeling, sitting on the floor/low chairs, walking, and exposure to weather. How do you feel you can perform these duties?

Excellent Good Fair Poor

Applicants Name:______

What is your primary language spoken?

English Spanish Other ______

What is your primary language written?

English Spanish Other ______

How would you rate your reading skills?

Excellent Good Fair Poor Unable

How would you rate your math skills?

Excellent Good Fair Poor Unable

How would you rate your comprehension skills?

Excellent Good Fair Poor

How would you rate your listening skills?

Excellent Good Fair Poor

How would you rate your patience with others?

Excellent Good Fair Poor

Why do you wish to be a Foster Grandparent?:______

______

Background:

Have you ever been found guilty of or pled guilty to a misdemeanor or felony (including nolo contender, no contest, and/or deferred adjudication?: Yes No

Are you required to register as a sex offender?: Yes No

Yes No If Yes to any of the above, Please Describe including year: ______
______

Please List Two (2) Character References Not Related to you:

Name Complete Address Phone

1. ______

2. ______

Applicants Name:______

Availability:

Willing To Serve: Mornings Afternoons

Monday Tuesday Wednesday Thursday Friday

Station(s) you are interested in serving at:______

(Not all stations may have openings)

How did you learn about the Foster Grandparent Program?______

Contact In Case Of Emergency:

Name: ______

Address:______

Phone: ______Relationship:______

Next of Kin:

Name: ______

Address:______

Phone: ______Relationship:______

Name of your Physician:

Name: ______Hospital:______

Phone:______

Applicants Name:______

Consent & Certifications:

Criminal Background Consent:

I give my permission for the Concho Valley Council of Governments to obtain information relating to my criminal history record through the Texas Department of Public Safety (TXDPS). The criminal history record, as received from the reporting agency, may include arrest and conviction data as well as plea again and deferred adjudications. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history record check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification if I dispute this record as received.

I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify the volunteer center of Tom Green County and each of their officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member.

______

Initial

General Release:

I hereby give the Foster Grandparent Program and the Concho Valley Council of Governments, its representatives or outside interests, full permission to use my name, case history, and photograph for publicity purposes. By doing this the Foster Grandparent Program can better serve older adults through improved public awareness generated by printed materials, displays, motion pictures, television, radio, videotape and/or the press.

I also understand and consent that:

1. If my story/photo is to be used in a future project, the Foster Grandparent Program and the Concho Valley Council of Governments will make a reasonable attempt to contact me again for verbal reauthorization, but such reauthorization is not necessary for re-use of my story/photo in future projects.

2. I will receive no payment or other compensation for present and/or future use of my story/photo.

______

Initial

Volunteer Confidentiality:

I understand that serving as a Foster Grandparent volunteer I will be serving children and will have knowledge about their problems, progress, performance and records. I understand that I am bound by the confidentiality laws, during and after my services, to a child as a volunteer. I understand that I am bound by the confidentiality laws, during and after my services, with regard to the Volunteer Station, the children at the Volunteer Station, and other Foster Grandparents.

I understand that if I give an unauthorized disclosure of information, I could be prosecuted under state and/or federal laws. Any such disclosure could result in immediate termination as a volunteer with the Foster Grandparent Program.

I agree to maintain confidential all information that I have knowledge of regarding the children, Volunteer Station, and Foster Grandparents.

______

Initial

Applicants Name:______

Service Agreement:

I am willing to serve as a Volunteer in the Foster Grandparents Program (FGP) of the Concho Valley. I will be scheduled to work a minimum of 15 hours per week, but no more than 40 hours per week. I understand that by contributing 15 hours per week I will earn the following benefits:

· Personal Leave.

· 12 Paid Holiday a year.

· On-duty supplemental insurance.

· Annual physical exam and tuberculosis test (TB) provided by La Esperanza Clinic.

· Mileage reimbursement of $0.35 per mile to and from my work stations if I drive my own vehicle (when funds are available) <or>

· Free transportation from the Concho Valley Transit (CVTD) if I do not drive my own vehicle.

I will contact my Station Supervisor and the FGP office by 9:00 a.m. if I will be absent from work due to illness or other unforeseen circumstances. Unexcused or frequent absences may be cause for my suspension or discharge from the FGP.

I also understand I am required to attend monthly In-Service trainings at the Concho Valley Council of Governments office in San Angelo. These monthly In-Services are mandatory. Only the FGP Director can approve my absence. If I am ill on the day of In-Service I will call the FGP office prior to 8:00 a.m.

______

Initial

I certify the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Name:______

(Please Print)

Signature:______

If the applicant is unable to sign his/her own name for consent, please complete the following information:

Representative:______

(Please Print)

Relationship to Applicant:______

Representative’s Signature:______

Please Submit Application, Copy of Auto Insurance and Copy of Driver’s License to:

Foster Grandparent Program

2801 W. Loop 306, Ste. A

San Angelo, TX 76904

(325) 944-9666

FGP Volunteer Application: Executive Board Approved-June 2014