Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Should any messages we leave be confidential?
Yes
No
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Relationship to You
*
Please briefly describe any previous or current volunteer work you have done:
Will your volunteer hours count towards a requirement? (i.e., mandated community service, class credit, work study):
*
Are you interested in any programs or tasks in particular while volunteering at OCS?
Are there any time limitations or other commitments that would restrict or prevent you from making a commitment to OCS?
*
Please list any licenses or clinical certifications that you hold:
What languages do you speak? (Include American Sign Language)
What times are you available to volunteer? (We ask that you commit at least one hour at a time)
*
Are there any tasks that you feel you are unable to perform due to special needs, allergies, etc. and/or any accommodations that you'd like us to be aware of?
Is there anything else you would like us to know?
Photo/Video Release
*
I give permission to be photographed and/or videotaped. I also permit Oberlin Community Services to use any photographs and/or videotapes of myself for any type of publicity which helps to secure the future of the agency.
Release and Covenant Not to Sue
I hereby release Oberlin Community Services, and all of its agents, employees, and voluntary board of directors, from any damages, directly or indirectly related to my assigned work at Oberlin Community Services, and from any responsibility and liability for any action initiated by me, while in or on any Oberlin Community Services property. I further agree not to sue Oberlin Community Services in connection with any of the foregoing.
I hereby represent and acknowledge that I am not an employee of Oberlin Community Services and am not entitled to and will not assert any claims as an employee against Oberlin Community Services, including such claims as workers’ compensation, unemployment, and other claims to which employees generally are entitled.
Pledge of Confidentiality
I understand that any information (written, verbal, or other form) obtained during the performance of my duties must remain confidential. This includes all information I may hear about clients, families, employees, and other associate organizations, as well and any other information otherwise marked or known to be confidential.
I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of the duty to maintain confidentiality. I further understand that any breach of the duty to maintain confidentiality could be grounds for immediate dismissal and/or possible liability in any legal action arising from such breach.
Please type your name in the box below for your signature:
*
Thank you!
Your application has been received.
Rosa, our volunteer and outreach coordinator, will be in touch with you soon.
