Safe Space, Inc. Volunteer Application

P.O Box 240

Louisburg, NC 27549

(919) 497- 5444

Personal Information:

Full Name: ______

Address: ______

City: ______State: ______Zip: ______

Date of Birth: ______

Age (Please Circle): 18-2021-4041-over

Contact Information:

Home Phone: ______Cell Phone: ______Other:______

E-Mail Address: ______

In case of an emergency, notify: ______

Phone: ______Relationship: ______

Education / Work Experience:

Highest Level of Education: ______

Current Employer: ______

Business Phone: ______

Previous Volunteer Experience / Community Affiliations: ______

References: Name: ______Name: ______

Title: ______Title: ______

Phone Number: ______Phone Number: ______

Please attach the most recent resume and a personal statement indicating why you would like to volunteer with Safe Space, Inc.

Volunteer Work Objectives:

In a brief statement please indicate why you would like to volunteer with Safe Space, Inc. and why you should be considered as a volunteer:

______

Rank your interest 1-6:

___ DV/SA Trainer___ Receptionist

___ Community events Volunteer___DV/SA Advocate Assistant

___ Thrift Store Assistant___Shelter Manager Assistant/Advocate

Please circle your volunteer work availability:

SUNDAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY
Morning Time
Evening
Time

Have you ever been arrested for anything other than a minor driving/traffic violation? NOYESIf so, please explain: ______

______

I understand a criminal check will be required to begin volunteering with Safe Space, Inc.

Applicant Signature______Date: ______

This agreement is intended to indicate the seriousness with which we treat our volunteers. The intent of the agreement is to assure and to indicate our commitment to do the very best we can to make your volunteer experiences here a productive and rewarding one.

Agency:

Safe Space, Inc. agrees to accept the services of ______and we commit to the following:

  1. To provide adequate information, training and assistance for the volunteers to be able to meet the responsibilities of their position and learn about the agency.
  2. To ensure diligent supervision of the volunteer and to provide feedback on the performance, and be provided with an appropriate job assignment.
  3. To respect the skills, dignity and individual needs of the volunteer and to do our best to adjust these individual requirements.
  4. To be receptive to any comments from the volunteer regarding ways in which we might mutually better accomplish our respective tasks.
  5. To treat the volunteer as an equal partner with agency and staff, jointly responsible for completion of the agency mission, without discrimination of any kind.

Volunteer:

I, ______, agree to serve as a volunteer and commit to the following:

  1. To perform my volunteer duties according to the policies and procedures of Safe Space, Inc. and share information with my supervisor for the purpose of carrying out the responsibilities of volunteering with the agency.
  2. To adhere to policies and procedures, including record keeping, requirements and confidentiality of agency and client information.
  3. To meet time and duty commitments or provide adequate notice so that alternate arrangements can be made.
  4. Adhere to the agency dress code.
  5. To receive constructive criticism and feedback as I carry out volunteer work requirements.

Empowerment Philosophy to Empowering Environment Interactions

As a volunteer, I agree to:

  • Be here first and foremost to provide service to victims of domestic violence and the community.
  • Create an environment of unity and equality. Staff shall recognize themselves as equal to the clients to whom they are providing services. This recognition of equality shall reflect in communication with clients and polices effecting clients.
  • Recognize that the victims or survivors I serve are not here because they are wrong or made poor choices but because they have been victimized and have requested my support.

Create an empowering environment when working with victims. This empowering environment will include:

  • Listening when a client needs support.
  • Offering options when providing services to the clients.
  • Allowing clients to make their own choices.
  • Sharing my honest, open feedback with clients in a constructive manner while respecting their own decisions.
  • Recognizing and admitting when I am judging a client or their choices.
  • Not limiting client options, support, or services due to my judgment or opinion.
  • Working my hardest to meet special needsof the client.
  • Embracing diversity presented by all clients including differences in race, language, culture, sexual orientation, age, spirituality, abilities, and experience.
  • Invest in open and honest communication with my fellow team members.
  • Dialogue with fellow team members when I have concerns about their behavior, their actions, or statements they have made to me.
  • Be open to hearing and responding to concerns about my behavior, action, or statements that I have made to others on the team.
  • Live up to the commitments that I have made to fellow team members. I will also be willing to seek support and assistance, as needed so that I can successfully accomplish these commitments.
  • Maintain a positive attitude focusing in the positive aspects of team members and the agency when interacting in the community.
  • Give and receive appreciation, compliments, feedback, and constructive criticism.
  • Be open to the different styles, attitudes, and opinions of other team members. Be willing to dialogue with team members when I feel their style, attitude, or opinion is in conflict with these agreements or the philosophy and mission of Safe Space, Inc.
  • Commit to participating in on-going dialogue about action towards program improvement.

Statement of Guiding Principles for Safe Space, Inc. Volunteers

  1. Confidentiality

In general, disclosure of any conversation between you and a client, without written permission, is prohibited. Any discussion with professionals or friends outside of the agency, without the written permission of the client, is prohibited and constitutes a breach of confidentiality. This rule may be waived when dealing with homicide, suicide, or child abuse/ neglect cases. For further instructions in these cases, contact your supervisor, the Executive Director.

  1. Liability

Failure to comply with the provision of the confidentiality rules will result in the immediate dismissal of the volunteer and may constitute a misdemeanor and be punishable is fine or imprisonment. Volunteers who have access to client information shall be liable in the same manner as employees.

  1. Representation

You represent the agency whenever you are working with client or professionals from other organizations. When asked your opinion, please remember Safe Space, Inc. empowerment philosophy. (See Attached)

  1. Never coerce or dictate a course of action to a client

You may offer options for a client. In keeping with our empowerment philosophy we do not offer our opinions, or make judgments when working with a client.

  1. Staff and Volunteer phone numbers are confidential

Never disclose this information to a client or anyone outside the agency. In case of emergency, take messages and make the contact yourself.

  1. The use of physical force or punishment when working with clients or client’s children

It is not acceptable and will be cause for immediate termination as a volunteer of Safe Space.

  1. Sexual relationships with clients are prohibited

Engaging in such relationships constitutes grounds for immediate dismissal

  1. Consumption of alcohol or any mind altering drug during a volunteer shift is prohibited.
  2. Take care of yourself!

We strongly discourage establishingpersonal relationships with clients. Making yourself emotionally, psychologically, physically available to a client, when not on call, is prohibited and not healthy for you or the client. It can compromise your safety and negates our philosophy of empowerment. If you struggle maintaining healthy, working relationships with our clients, we can encourage you to discuss the matter with your supervisor.

I have read, understand, and commit to the above listed Empowerment Philosophy to Empowering Environment Interactions and Guiding Principles of Safe Space, Inc. I will constantly work to identify and continue behaviors and actions are not empowering. I understand that I will be accountable for using or choosing not to use the guidelines listed above.

Signed:

Volunteer: ______Date: ______

Safe Space Personnel: ______Date: ______

Volunteer Confidentiality Statement

By signing this document I agree that I understand and will adhere to the following:

To hold in confidence all information regarding client of Safe Space, Inc. I will not discuss information concerning clients with anyone other than Safe Space staff, unless authorized to do so by the Executive Director.

I will not remove from the office any written record or copies of information pertaining to clients. Any written record I may be responsible for producing shall be remain part Safe Space, Inc. records.

To accept full responsibilities for maintaining the confidential and private nature of all records and information with which I have involvement.

I understand that it is Safe Space, Inc. policy that no employee, volunteer or other agent shall engage in any conduct that would obstruct justice. All Safe Space, Inc agents shall provide full cooperation to the law enforcement officials who are carrying out their sworn duties with regards to the services of process and the execution of search and arrest warrants.

I understand the Confidentiality policies of Safe Space, Inc. as they were explained to me. I also have read and understand them in their entirety. I am aware that the policies are to insure the privileged and confidential nature of client information and herby agree to protect and preserve the confidential nature of all client information to which I may have access.

Signed:

Volunteer: ______Date: ______

Executive Director: ______Date: ______

Release from Liability

In order to participate in the Safe Space, Inc. volunteer program I, ______hereby release all Safe Space, Inc. staff volunteers from any and all liability claims, demands, actions and cause of actions, whatsoever, arising out of, or related to, any loss or damage to my personal property, and/or injury (including death), that may be sustained by me at Safe Space, Inc. staff member or volunteer.

Signed:

Volunteer: ______Date: ______

Safe Space Personnel: ______Date: ______

Thank you for completing your application. We look forward to interviewing you and considering your volunteer application

Please email the application to or fax to (919) 497-1761

Or mail to PO Box 240 Louisburg, NC 27459.

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