Athens County Board of Mr/Dd

Instructions for completing your application to volunteer with

The Athens County Board of Developmental Disabilities

and Atco Adult Services:

Please read carefully. Print this application out and complete by hand. Please write legibly! Your signature is required in several places.

Page 2 is self-explanatory.

Page 3 only needs to be completed if you are under the age of 18.

Page 4 is a local police check to make sure that all of our volunteers are safe and responsible individuals. Don’t sign the “witness” line; we will sign that once you have submitted this application.

Pages 5 and 6 are reference request cover letters. Where it says “To:” put the name and a complete address for the reference listed. We would like two (2) Professional references: advisors, professors, clergy, employers, etc. We will mail the reference requests out from Atco.

Pages 7, 8, and 9, read the information, sign and date. Once again, don’t worry about the “witness” signature. We will sign once your application has been submitted.

Page 10, just sign and include with your packet. This is for office use only.

Please note: Anyone volunteering with The Athens County Board of Developmental Disabilities and Atco Adult Services, MUST submit an application prior to beginning to volunteer.

The Athens County Board of Developmental Disabilities and Atco Adult Services

VOLUNTEER APPLICATION

Name: ______Date: ______

Address: ______Phone:______

______E-Mail: ______

Date of Birth: ______SSN: ______

Contact in case of emergency: ______Phone:______

Special Interests/Talents/Accommodations:______

______

Volunteer Experience:______

Please give two (2) personal/professional references not related to you:

1. ______

NameAddressPhone

2. ______

NameAddressPhone

When are you available to volunteer?

Day and Time:Mon. ______Tues. ______Wed. ______

Thurs. ______Fri. ______Sat. ______Sun. ______

Which category of volunteer do you fall under?

Student Teacher Teen TeacherOWE Student

Internship High School Volunteer Field Experience

College Volunteer Parent Volunteer Other Volunteer

I certify that I have given my permission for The Athens County Board of DD and Atco Adult Services to seek a copy of my arrest/conviction and motor vehicle record, and I understand that the information will be held in the strictest confidence, and that I can revoke this consent at any time by written request.

I hereby release The Athens County Board of DD and Atco Adult Services from any and all liability from the gathering of this information.

______

SignatureDate

Office Use Only

Date application received: ______

Assignment and date: ______

The Athens County Board of Developmental Disabilities and Atco Adult Services

VOLUNTEER PARENTAL PERMISSION FORM

***Fill out only if under age 18***

Volunteer’s Name: ______

Age: ______Date of Birth: ______

Address: ______

City: ______State: ______Zip: ______

Telephone: ______

VOLUNTEER PARENTAL/AGENCY LIABILITY RELEASE FORM

I, ______, as a parent/legal guardian of

______give my permission for

______to serve as a volunteer with The Athens County Board of Developmental Disabilities and Atco Adult Services. This permission includes volunteer positions within a facility or in the community, as well as transportation to and from activities, as necessary.

In consideration of my son’s/daughter’s willingness to serve as a volunteer for The Athens County Board of Developmental Disabilities and Atco Adult Services, I understand that The Athens County Board of Developmental Disabilities and Atco Adult Services will not assume responsibility for any liability arising out of my child’s willful neglect or intentionally wrongful acts. I agree to release, reimburse, and hold harmless The Athens County Board of Developmental Disabilities and Atco Adult Services’ consumers, and their families, staff members, or any other volunteers from any liabilities, claims, or injuries arising out of my child’s wrongful acts or negligence.

Program Coordinator:Signature of Parent/Guardian:

______

DateDate

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize and request the Police Department of the City of Athens, Ohio, or the Athens

County Sheriff’s Department to release from its records, to the individual or agency designated

below, any and all information concerning me, including, but not limited to my arrest record. I

further release the City of Athens, Ohio, the Athens City Police Department, the Athens County

Sheriff’s Department, the County of Athens, and Athens County Board of Developmental

Disabilities and Atco Adult Services, and their employees and agents from any and

all liability whatsoever arising out of their release of such information.

I understand that this information will only be used to verify my suitability for volunteer services

and all information gathered will be handled in the strictest confidence.

PLEASE PRINT:

______

Name (last, first, middle, & maiden)

____________

Signature/DateWitness Signature

______

Date of Birth

______

Social Security Number

Agency Requesting Information:

Athens County Board of Developmental Disabilities and Atco Adult Services

21 S. Campbell Street

Athens, Ohio 45701

The Athens County Board of Developmental Disabilities and Atco Adult Services

21 S. Campbell Street, ATHENS, OHIO 45701

Phone: (740) 592-6659 Fax: (740) 594-7814

Reference Request

Date:______

To:______

______

I have applied to The Athens County Board of Developmental Disabilities and Atco Adult Services as a volunteer, and I desire that they be advised of your knowledge regarding my ability to volunteer in their agency. I hereby release you from any and all liability of damage for providing the information requested.

Volunteer Applicant’s Name (print): ______

Signature of Applicant: ______Date: ______

______, has applied as a volunteer with our agency. He/she has listed you as a reference and authorized us to contact you to obtain information, which will be used to determine their qualifications for volunteering with The Athens County Board of Developmental Disabilities and Atco Adult Services. To the best of your ability, please respond to the attached questions. A timely response is appreciated and will allow us to determine if this person is a qualified volunteer. All responses are kept strictly confidential and will not be released to any other source. Thank you for taking the time to complete this reference form.

Sincerely,

Jeff Bierlein, Community Inclusion Coordinator

Atco Adult Services
21 S. Campbell St.
Athens OH 45701
Phone: (740- 592-6659
Fax: (740) 594-7814 / Beacon School
801 W. Union St.
Athens OH 4701
Phone (740) 594-3539
Fax: (740) 593-3189 / Case Management/
Community Support
9033 Lavelle Rd.
Athens OH 45701
Phone; (740-592-6006
Fax 592-6066

The Athens County Board of Developmental Disabilities and Atco Adult Services are an equal opportunity employer and provider of services.

Name of Volunteer Applicant: ______

Do you think this applicant could successfully work with persons having a disability?

Yes No Why? (Use back of paper, if necessary.)

How long have you known this person? ______.

Do you feel that the applicant is dependable and reliable?

Yes No Why?

Would you recommend that this person be accepted as a volunteer by our agency?

Yes No Why?

Do you feel that this applicant gets along well with others?

Yes No

If you were recruiting volunteers for this agency, would you recruit this person?

Yes No Why?

Can you think of any reason why we should not consider using this individual as a volunteer?

Yes No If yes, please explain:

Signed: ______Date: ______

The Athens County Board of Developmental Disabilities and Atco Adult Services

21 S. Campbell Street, ATHENS, OHIO 45701

Phone: (740) 592-6659 Fax: (740) 594-7814

Reference Request

Date:______

To:______

______

Volunteer Applicant’s Name (print): ______

Signature of Applicant: ______Date: ______

Sincerely,

Jeff Bierlein, Community Inclusion Coordinator

The Athens County Board of Developmental Disabilities and Atco Adult Services are an equal opportunity employer and provider of services.

Name of Volunteer Applicant: ______

Do you think this applicant could successfully work with persons having a disability?

Yes No Why? (Use back of paper, if necessary.)

How long have you known this person? ______.

Do you feel that the applicant is dependable and reliable?

Yes No Why?

Would you recommend that this person be accepted as a volunteer by our agency?

Yes No Why?

Do you feel that this applicant gets along well with others?

Yes No

If you were recruiting volunteers for this agency, would you recruit this person?

Yes No Why?

Can you think of any reason why we should not consider using this individual as a volunteer?

Yes No If yes, please explain:

Signed: ______Date: ______

The Athens County Board of Developmental Disabilities and Atco Adult Services

Liability Agreement

As a volunteer with The Athens County Board of Developmental Disabilities and Atco Adult Services, I agree to abide by the following liability policies and rules:

If I am granted permission to drive an ACBDD vehicle by a Program Director in order to transport a consumer, I would be covered under the ACBDD’s insurance.

In the event of negligence on my part, which results in harm to a consumer, the consumer would be covered under the ACBDD’s insurance.

I will not be covered for any injuries as a result with my interactions with a consumer. If I am injured, I must rely on my own health/medical insurance.

______

SignatureDate

______

WitnessDate

The Athens County Board of Developmental Disabilities and Atco Adult Services

CONFIDENTIALITY AGREEMENT

To comply with federal and state standards using Public Law 94-142 and House Bill 455 as a guide, I understand that all personal information regarding individuals with developmental disabilities shared with me shall be considered privileged and strictly confidential.

Each volunteer shall respect the confidential nature of the information he/she acquires regarding students, adults, and/or their families. Under no circumstances should this information be discussed except within the professional context of job responsibilities.

A breach in confidentiality by any volunteer shall be considered a violation of Ohio Revised Code 5123:83, Public Law 94-142, and House Bill 455.

______

SignatureDate

______

WitnessDate

The Athens County Board of Developmental Disabilities

and Atco Adult Services Contract

In consideration for The Athens County Board of Developmental Disabilities and Atco Adult Services permitting me to be a volunteer, I, ______, understand and agree to abide by and be responsible for the following:

To become familiar and observe The Athens County Board of Developmental Disabilities and Atco Adult Services policies and procedures.
To be reliable in reporting for work, to notify The Athens County Board of Developmental Disabilities and Atco Adult Services in advance of any absence or tardiness, and to provide The Athens County Board of Developmental Disabilities and Atco Adult Services with an accurate record of hours volunteered by using the sign in/sign out logs.
To respect the rights of people with disabilities at all times.
To protect the privacy of consumers and to keep confidential any information which becomes available to me.
To notify the Community Inclusion Coordinator of any concerns that I may have with any volunteer position.
To notify the Community Inclusion Coordinator of any intention to terminate my volunteer experience with at least a two weeks notice.

The Athens County Board of Developmental Disabilities and Atco Adult Services staff is responsible for the following:

To provide a general orientation to the program and specific training for the position for which you are placed.
To provide a volunteer position and responsibilities which are suited to your interest and abilities.
To provide direct supervision and periodic feedback/evaluation by The Athens County Board of Developmental Disabilities and Atco Adult Services staff.
To notify you when there is any status change in the volunteer position that you serve.
To respond to your concerns whenever they are expressed.
To document and recognize your contributions to our program and to provide references when requested.

I give The Athens County Board of Developmental Disabilities and Atco Adult Services permission to use slides or photographs of me for educational and publicity purposes, including illustrations, publications, and news media.

______

SignatureDate

______

WitnessDate

The Athens County Board of Developmental Disabilities and Atco Adult Services

VOLUNTEER ORIENTATION CHECKLIST

Name of Volunteer:______Level:______

The following information will be shared with volunteers as part of their orientation:

xxx / Seizure Recognition and Related Information
xxx / Communication Hints
xxx / The Athens County Board of Developmental Disabilities and Atco Adult Services Information
xxx / Table of Organization
Other, list
Other, list
Other, list
Other, list

I have completed an orientation for volunteering with The Athens County Board of Developmental Disabilities and Atco Adult Services and have received copies of the information checked above.

My volunteer experience will be supervised by Jeff Bierlein, Community Inclusion Coordinator.

______

Volunteer signatureDate

______

Staff completing orientation signatureDate

For office use:

The following have been received:

_____ References

_____ BCI

_____ Driving Abstract

_____ Liability Agreement

_____ Confidentiality Agreement

_____ Volunteer/Agency Contact