Safe at Home Family Partner Volunteer Application

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Middle Initial Last

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address City State ZIP Code

Home Phone

Cell Phone

Email Address

Are you of Hispanic or Latino descent?(Required)

Yes

I do not wish to provide this information

Please indicate how you identify yourself (select one or more)(Required)

List any prior names and aliases, including maiden names, married names, name changes, and any name you have used or been known by below.

Have you lived out of state during the past 5 years for more than 60 days?(Required)

Yes

If you answered ‘yes’ to the above question, please list all previous addresses below.

Emergency Contact Information

Full Name(Required)

First Last

Relationship to you(Required)

Address (City, State)(Required)

City State

Phone Number(Required)

Personal History

Have you ever been arrested, charged, and/or convicted of a potentially disqualifying crime?(Required)

To help you answer this question, see 'Potentially Disqualifying Conviction List' to learn what is potentially disqualifying for the position.

Yes

I am not sure

If you answered ‘yes’ above, provide as much detail as possible about each event in your history, including:(Required)

• The date of each event
• The crime (the name of the crime)
• Details about the crime (the location, what happened, how were you involved)
• Outcome of the crime (did you have any court-ordered requirements? Explain your success with these requirements
• Changes since this history (even though you have history, explain how you have changed, and your ability to work or be in the placement you are requesting.

Note: Answering "yes" will not automatically prohibit individuals from becoming a volunteer but will be considered with respect to time, circumstances, seriousness, and relationship to volunteer responsibilities.

Have you ever been involved with an investigation of potentially disqualifying abuse as an accused person, reported perpetrator, or alleged perpetrator, resulting in a founded or substantiated outcome?(Required)

To help you answer this question, see 'Potentially Disqualigying Conviction List' to learn what is potentially disqualifying for the position.

Yes

I am not sure

If you answered ‘yes’ above, provide as much detail as possible about each incident in your history, including:(Required)

To help you answer this question, request the explanation of potentially disqualifying abuse list to learn what is potentially disqualifying for the position.
• The date of each event (around the time that it occurred)
• The type of the abuse (the allegation against you)
• The details about the abuse (the location, what happened leading up to the abuse investigation, how you were involved)
• The details about the investigation (what happened during the investigation, how you were involved, etc.)
• Outcome of the abuse investigation (did you have any actions or training you were required to do? Explain your success with these requirements
• Changes since this history (even though you have history, explain how you have changed, and your ability to work or be in the placement you are requesting)

Note: Answering "yes" will not automatically prohibit individuals from becoming a volunteer but will be considered with respect to time, circumstances, seriousness, and relationship to volunteer responsibilities.

Availability to Volunteer

When are you available to begin volunteering?(Required)

Approximately how many hours per month would you like to volunteer?

Enter a number or use the arrows on the right.

May we contact you to share family cases that may be outside your preferred volunteer days/times?(Required)

Yes

Indicate the time frames you would like to be considered for volunteering

Monday(Required)

Not Available

Tuesday(Required)

Not Available

Wednesday(Required)

Not Available

Thursday(Required)

Not Available

Friday(Required)

Not Available

Saturday(Required)

Not Available

Sunday(Required)

Not Available

Is there anything else you would like to share about your availability?

Qualifications, Experience, Skills

List any qualifications and/or experience that would be relevant to the volunteer position

(e.g., Diploma, Degree, Certificate, Work/Volunteer Experience)

List any other trainings, certifications and/or skills you would like to include

(e.g., First Aid/CPR)

List any languages you can speak, read and/or write

References

Reference Person 1

Name(Required)

Relationship to you(Required)

Phone Number(Required)

May we contact this person(Required)

Yes

Reference Person 2

Name(Required)

Relationship to you(Required)

Phone Number(Required)

May we contact this person(Required)

Yes

Application Agreement

Application Agreement Signature(Required)

My signature below certifies that all statements made on this application are true, complete, and correct to the best of my knowledge and belief. I understand these statements are subject to verification. I understand that falsification on this application can disqualify me from consideration or result in my volunteer services being denied. Furthermore, my signature below provides my authorization to the Marion & Polk Early Learning Hub to conduct a background check as needed, as well as reference checks to determine my suitability for placement. Your typed name qualifies as your signed signature.

Application Agreement Date(Required)

Volunteer Background Check Release of Information

Authorization for Disclosure, Sharing and Use of Individual Information

By signing this form, I hereby authorize the State of Oregon Department of Human Services to perform an Oregon criminal history and Oregon child welfare history record information check and share that information with Marion and Polk Early Learning Hub (MPELH) relative to my application for volunteer services for the MPELH Safe at Home Program.

First Name MI Legal Last Name

Other names

(maiden, married, aliases)

Address

Street Address City State ZIP Code

Phone

Checkmark the document you would like to submit information for and enter that information below. Please note that ODHS will indicate that fingerprints are needed if the identification submitted is anything other than an Oregon driver's license or Oregon identification card.

Document:

List the Issuing State or Authority of the document:

List the document number:

List the document expiration date:

Upload Your Document

You may upload up to 2 documents.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 8 MB, Max. files: 2.

Acknowledgement

• I was given the chance to ask questions about this form and what it does.
• I understand what this form means, and I approve of the disclosures or releases listed.
• I understand that state and federal law protect information about services I receive from any listed agency, business, organization, person.
• This authorization is valid for one year from the date I sign it unless otherwise noted.
• I understand that I may, in writing or verbally, revoke this consent at anytime except to the extent that disclosure was made prior to the time I revoked it.
• I understand that federal or state law prohibits re-disclosure of information, without authorization by me.
• I understand someone may need to contact me about this form to confirm my identity. They may also need to get more information.
• I understand that deciding not to sign this form may prevent me from providing volunteer services with Marion and Polk Early Learning Hub Safe at Home Program.

I am signing this authorization of my own free will.

Acknowledgement Name

Acknowledgement Signature

Acknowledgement Date

Emergency Contact Information

Personal History

Availability to Volunteer

Qualifications, Experience, Skills

References

Application Agreement

Volunteer Background Check Release of Information

Acknowledgement

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Emergency Contact Information

Personal History

Availability to Volunteer

Qualifications, Experience, Skills

References

Application Agreement

Volunteer Background Check Release of Information

Acknowledgement

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