"Program Volunteer Application - Ymca of Greater Long Beach" - California

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YMCA of Greater Long Beach
PROGRAM VOLUNTEER APPLICATION
PERSONAL
(please give your FULL, LEGAL name)
Last Name
First Name
Middle Initial
Home Phone: (
)
___day ____evening
I prefer to be called:
Alternate Phone: (
)
___work___cell___other
Street Address:
Email Address:
City, State, Zip:
Best time to reach you:
Volunteer position you’re applying for:
I prefer ___home phone ___alt. phone ___e-mail contact.
Are you 21 years or older?: Yes ______ No ______ If No, birth date: __________
Are you a YMCA Member?: Yes_____ Branch:
No_____
Emergency Contact Name:
Relationship:
Phone number:
(Please list someone OUTSIDE your home – in the event of an emergency, we would automatically contact your home first, then this backup contact.)
Have you been convicted of any criminal offense (other than a juvenile offense now expunged from your record) or released from prison in the past ten years?
Yes_____
No_____
If Yes, describe in full:
STUDENT VOLUNTEERS
Are you looking to fulfill a school requirement or will you receive school credit for your service?
Yes_____ No_____
IF YES, name of school:
Is this a Service-Learning requirement or opportunity? Yes_____ No_____
Number of Hours needed:
Deadline to Complete Hours:
COMMUNITY SERVICE VOLUNTEERS
Are you looking to complete Court Ordered Community Service Hours? Yes_____ No_____
IF YES, offense:
Number of hours needed:
Deadline to complete hours:
Parole/Probation Officer’s name:
Phone:
RELATED BACKGROUND
Have you previously volunteered for or been employed by another YMCA? Yes_____
No_____
If Yes, please list all YMCAs and dates:
YMCA:
City, State:
Dates worked
AND/OR
Dates volunteered
1)
1)
1)
1)
2)
2)
2)
2)
Current/most recent employer:
Location:
Position:
How long:
Current/most recently attended school:
Location:
Current year in school/highest level completed:
Date completed (or graduation date):
Other relevant background, training or volunteer experiences:
Certifications held (include date of expiration):
No
Do you have a child/ren participating at the YMCA? If yes, please state first and last name of child/ren.
Have you ever coached at the YMCA before?
Which sports are you interested in coaching? Which season?
REFERENCES
For the safety of our participants, staff and volunteers, we complete at least 2 reference checks on every program volunteer. Appropriate
references may include supervisors, co-workers, faith leaders, teachers or school counselors. Please do not list relatives/household members
or friends.
1
Name:
Phone number:
Relationship to you:
Email:
2
Name:
Phone number:
Relationship to you:
Email:
3
Name:
Phone Number:
Relationship to you:
Email:
YMCA of Greater Long Beach
PROGRAM VOLUNTEER APPLICATION
PERSONAL
(please give your FULL, LEGAL name)
Last Name
First Name
Middle Initial
Home Phone: (
)
___day ____evening
I prefer to be called:
Alternate Phone: (
)
___work___cell___other
Street Address:
Email Address:
City, State, Zip:
Best time to reach you:
Volunteer position you’re applying for:
I prefer ___home phone ___alt. phone ___e-mail contact.
Are you 21 years or older?: Yes ______ No ______ If No, birth date: __________
Are you a YMCA Member?: Yes_____ Branch:
No_____
Emergency Contact Name:
Relationship:
Phone number:
(Please list someone OUTSIDE your home – in the event of an emergency, we would automatically contact your home first, then this backup contact.)
Have you been convicted of any criminal offense (other than a juvenile offense now expunged from your record) or released from prison in the past ten years?
Yes_____
No_____
If Yes, describe in full:
STUDENT VOLUNTEERS
Are you looking to fulfill a school requirement or will you receive school credit for your service?
Yes_____ No_____
IF YES, name of school:
Is this a Service-Learning requirement or opportunity? Yes_____ No_____
Number of Hours needed:
Deadline to Complete Hours:
COMMUNITY SERVICE VOLUNTEERS
Are you looking to complete Court Ordered Community Service Hours? Yes_____ No_____
IF YES, offense:
Number of hours needed:
Deadline to complete hours:
Parole/Probation Officer’s name:
Phone:
RELATED BACKGROUND
Have you previously volunteered for or been employed by another YMCA? Yes_____
No_____
If Yes, please list all YMCAs and dates:
YMCA:
City, State:
Dates worked
AND/OR
Dates volunteered
1)
1)
1)
1)
2)
2)
2)
2)
Current/most recent employer:
Location:
Position:
How long:
Current/most recently attended school:
Location:
Current year in school/highest level completed:
Date completed (or graduation date):
Other relevant background, training or volunteer experiences:
Certifications held (include date of expiration):
No
Do you have a child/ren participating at the YMCA? If yes, please state first and last name of child/ren.
Have you ever coached at the YMCA before?
Which sports are you interested in coaching? Which season?
REFERENCES
For the safety of our participants, staff and volunteers, we complete at least 2 reference checks on every program volunteer. Appropriate
references may include supervisors, co-workers, faith leaders, teachers or school counselors. Please do not list relatives/household members
or friends.
1
Name:
Phone number:
Relationship to you:
Email:
2
Name:
Phone number:
Relationship to you:
Email:
3
Name:
Phone Number:
Relationship to you:
Email:
Conditions of Volunteer Participation and Release from Liability
The YMCA of Greater Long Beach is an Association that welcomes people of all ages, ethnic groups, and
religious affiliations to unite in a common effort to put Judeo-Christian principles and values into practices,
through programs that develop healthy spirit, mind, and body for ourselves, our families, our children and
community.
Background Certification: I certify that all of the information provided on this application is true and
complete. I authorize the YMCA to investigate and verify any and all of the information I have submitted.
Because the YMCA’s priority of providing a safe environment for children and youth, I understand the YMCA may
order a criminal history check, and I authorize this investigation.
Volunteer Terms: I agree to abide by the YMCA of Greater Long Beach’s policies, procedures and Code of
Conduct. I understand the YMCA does not provide any health benefits (i.e. medical, dental, workers
compensation, etc.) or any accident insurance for me as a volunteer; I understand it is my responsibility to
provide this coverage. I understand that the YMCA of Greater Long Beach does not trade volunteer services for
membership or program fees.
Property Loss: I understand the YMCA is not responsible for my personal property lost, damaged or stolen
while participating in YMCA volunteer activities.
Medical Treatment: I give permission for YMCA representatives to provide emergency care for me, to arrange
for transport to an emergency center for treatment, and I consent to medical treatment deemed immediately
necessary or advisable by a physician if I am unable to act on my own behalf.
Photograph Permission: I give permission for the YMCA to use, without limitation or obligation, photographs
or other media that may include my image or voice to promote or interpret YMCA programs.
Release from Liability: I acknowledge the conditions of volunteer participation as stated above. If applicant
is under age 18, I give permission for my dependent to participate in YMCA volunteer activities. I understand
that accidents can sometimes happen. In exchange for the YMCA allowing me, or my dependent, to volunteer, I
hereby release the YMCA of Greater Long Beach, its agents, servants and employees from all liability and
ordinary negligence, including all claims for injury, illness, death, loss or damage, which may result from my, or
my dependent’s, participation as a volunteer.
_____________________________________________
___________________
Volunteer Applicant Signature
Date
_____________________________________________
___________________
Parent or Guardian, if Volunteer Applicant is under age 18
Date
For YMCA of Greater Long Beach Staff Use Only
Branch/Site:
Program Placement(s):
Program Director/Supervisor:
Approximate Start Date:
Mandatory:
Follow-up (dates):
___references (minimum 2)
Background forms to HR_________
___Safety/Child Abuse form
Data entry completed___________
___Checked Megan’s Law Website
YMCA OF GREATER LONG BEACH
VOLUNTEER DISCLOSURE AUTHORIZATION
P.O. Box 90995
Long Beach, CA 90809-0995
Phone: (562) 279-1700
Fax: (562) 279-1705
As part of the application process for employment with the YMCA of Greater Long Beach, I understand that the
YMCA of Greater Long Beach and/or its agents may conduct an investigation of my personal information. The
investigation might include, but is not limited to names and dates of previous/current employment, work
experience, workers' compensation claims, criminal history records (from state, federal and other agencies),
motor vehicle records, military records, names and dates of education institutions, credit history, and
bankruptcy records. I understand that these records may be used for the eligibility of my employment. I
authorize without reservation the full release of these records and for the YMCA of Greater Long Beach and/or
those parties contacted by the YMCA of Greater Long Beach to obtain information.
In addition, I release and discharge the YMCA of Greater Long Beach, and all of its agents and associates, any
expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process. I also
authorize the full release of the information described above, without any reservation, throughout any duration
of my employment at the YMCA of Greater Long Beach. I also certify that all information provided is correct and
complete on the application and my resume to the best of my knowledge. Any false statements or omissions will
be considered just cause for termination of employment.
Upon Request, the YMCA of Greater Long Beach will supply a copy of my report and my rights under the Fair
Credit Reporting Act. Requests may be directed to: YMCA of Greater Long Beach, P.O. Box 90995, Long Beach,
CA 90809-0995, or at: (562) 425-9986.
Volunteer’s Full Name: ______________________________________________________________________
Signature:__________________________________________________ Date: _________________________
Date of Birth: ______________ (This is used for criminal and driving records, month and day only)
Social Security Number: ____ - ____ - _____ Driver's License Number: __________________ State:
________
Current Address: ________________________________________________ Length of Residency: _________
Street Address, City, State, Zip
Dates
Street Address
City
State
Zip
YMCA OF GREATER LONG BEACH
VOLUNTEER CODE OF CONDUCT
1. In order to protect YMCA staff, volunteers, and program participants at no time during a YMCA program
may a volunteer be alone with a single child where others cannot observe them. As staff and volunteers
supervise children, they should space themselves in a way that other adults can see them.
2. Staff and volunteers shall never leave a child unsupervised.
3. Restroom supervision: Staff will make sure the restroom is not occupied by suspicious or unknown
individuals before allowing children to use the facilities. Staff will stand in the doorway while children are
using the restroom. This policy allows privacy for the children and protection for the staff (not being
alone with a child). If staff are assisting younger children, doors to the facility must remain open. No
child, regardless of age, should ever enter a bathroom alone on a field trip; always seen children in pairs.
4. Staff and volunteers should conduct or supervise private activities in pairs – diapering, putting on
bathing suits, taking showers, etc. When this is not feasible, staff should be positioned so that they are
visible to others.
5. Staff and volunteers shall not abuse children including:
a. Physical Abuse – striking, spanking, shaking, slapping
b. Verbal Abuse – humiliating, degrading, threatening
c. Sexual Abuse – inappropriate touch or verbal exchange
d. Mental Abuse – shaming, withholding love, cruelty
e. Neglect – withholding food, water, basic care, etc.
Any type of abuse will not be tolerated and may be cause to end volunteering.
6. Staff and volunteers must use positive techniques of guidance, including redirection, positive
reinforcement and encouragement rather than competition, comparison, and criticism. Staff and
volunteers will have age appropriate expectations and set up guidelines and environments that minimize
the need for discipline. Physical restraint is used only in pre-determined situations (necessary to protect
the child or other children from harm), is only administered in a prescribed manner and must be
documented in writing.
7. Staff will conduct a health check of each child, each day, as they enter the program, noting any fever,
bumps, bruises, burns, etc. Questions or comments will be addressed to the parent or child in a non-
threatening way. Any questionable marks or responses will be documented.
8. Staff and volunteers will respond to children with respect and consideration, and treat all children equally
regardless of sex, race, religion or culture.
9. Staff and volunteers will respect children’s rights to not be touched in ways that make them feel
uncomfortable, and their right to say NO. Other than diapering, children are not to be touched on areas
of their bodies that would be covered by a bathing suit.
10. Staff and volunteers will refrain from intimate displays of affection towards others in the presence of
children, parents and staff.
11. While the YMCA does not discriminate against an individual’s lifestyle, it does require that in the
performance of their job they will abide by the standards of conduct set forth by the YMCA.
12. Staff and volunteers must appear clean, neat, and appropriately attired.
13. Using, possessing or being under the influence of alcohol or illegal drugs during working hours is
prohibited.
14. Smoking or use of tobacco in the presence of children or parents during working hours is prohibited.
15. Profanity, inappropriate jokes, sharing intimate details of one’s personal life and any kind of harassment
in the presence of children or parents is prohibited.
16. Staff and volunteers must be free of physical and psychological conditions that might adversely affect
children’s physical or mental health. If in doubt, an expert should be consulted.
17. Staff will portray a positive role model for youth by maintaining an attitude of respect, loyalty, patience,
courtesy, tact, and maturity.
18. Staff and volunteers may not be alone with children they meet in YMCA programs outside of
the YMCA. This includes babysitting, sleepovers, and inviting children to your home. Any exceptions
require a written explanation before the fact and are subject to administrator approval.
19. Staff and volunteers are not to transport children in their own vehicles. Any exceptions require
pre-approved DMV driver checks and permission from administrator.
20. Staff and volunteers are NOT to date program participants under the age of 18 years of age.
21. Under no circumstances should staff or volunteer release children to anyone other than the authorized
parent, guardian or other adult, authorized by the parent or guardian (written parent authorization on
file with the YMCA).
22. Staff and volunteers are required to read and sign all policies related to identifying, documenting, and
reporting child abuse and attend training on the subject, as instructed by a supervisor.
I understand that any violation of this Code of Conduct may result in an end to the volunteer .
_____________________________________________________________
Printed Volunteer’s Name
____________________________________________ ________________
Volunteer’s Signature
Date