EMPLOYMENT AND HUMAN SERVICES

CHILDREN & FAMILY SERVICES

VISITATION VOLUNTEER APPLICATION

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Name Date of Birth

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Social Security Number Phone Number

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Home Address

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City, State Zip E-mail Address

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Emergency Contact Phone Number

______

Employed By (If Employed) Phone Number

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Address

May you be called at work? Yes No

Brief description of work: ______

______

Please list the times that you will be available to volunteer?

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
A.M.
P.M.

Formal Education (highest year of school completed): ______

Do you speak a foreign language?  Yes  No If yes, which language ______

Do you drive?  Yes  NoDo you have regular access to a car?  Yes  No

Do you have a health condition we should be aware of in case of an emergency?

 Yes  No

If Yes, describe: (such as history of back trouble, heart, epilepsy, diabetes, fainting, etc.)

______

Is there medication you must take?  Yes  No

Is there medication to which you are allergic?  Yes  No

If Yes, medication is: ______

Medical or Hospital InsurancePlan:______

Emergency Contact: ______

NameAddressPhone

Current community activities: ______

______

List current and previous volunteer work (list all previous volunteer work including brief description of duties and activities, dates of service.):

______

______

As a visitation volunteer, you may be required to attend court hearings to testify on your documented observations. Will you be able to arrange your schedule to attend these hearings? Yes  No

Are you willing to commit to six-months of volunteer service?  Yes  No

What are your reasons for wanting to participate as a visitation volunteer?

______

______

______

Have you had any personal experience(s) involving:

Child Welfare Foster Care

Court System Other agencies offering services to a child

If so, please explain: ______

______

How did you learn of our program:______

______

Have you ever been convicted of a crime other than a traffic violation?  Yes  No

If yes, what charge? ______Date convicted: ______Where ______

Do you consent to a routine check of your criminal records?  Yes  No

Please list three references of people who know you well, two of whom are not related to you, preferably for whom you have worked in either a paid or volunteer capacity. If you are currently working, either paid or as a volunteer, please include the name of your supervisor.

NameAddressZip CodePhoneRelationship

1. ______

2. ______

3. ______

Children & Family Services reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All information obtained will be held in the strictest confidence. I have been informed against and accept responsibility for any breach on my part respecting confidential information. I have read the Policy adopted by the Contra Costa County Board of Supervisors on volunteer programs. In return for the benefits provided by Contra Costa County in case of my illness, injury, death or third party liability while providing, or resulting from acts or occurrences within the scope of my authorized volunteer services, and for my right to authorized expense reimbursement, I waive any claim on my behalf of my heirs, representatives, and assigns against the County of Contra Costa any other agency governed by the Board of Supervisors, and any agent, officer or employee thereof for illness, injury, debts or without limitation, other harm arising from my volunteer services, whether or not authorized.

Under penal code 290.95 I am required to disclose if I am a registered sex offender upon submission of an application for a position involving children. My failure to disclose this fact could result in my arrest, prosecution, and likely fine and imprisonment. By placing my name below, I declare under penalty of perjury, that I am not required pursuant Penal Code 290.95 to disclose that I am a registered sex offender and that I have not suffered convictions for sex or drug related offenses or for crimes of violence, and there are no criminal charges pending against me.

I hereby release Employment and Human Services Department from liability for damage which may result from checking criminal background and references.

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Applicant Signature Date

PLEASE RETURN YOUR COMPLETED APPLICATION AND A PHOTOCOPY OF YOUR DRIVERS LICENSE TO:

Children & Family Services

Volunteer Visitation Program, Rhonda Smith

40 Douglas Drive

Martinez, CA94553

(925) 313-1696 fax: (925) 313-1758