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CHILD ADVOCATES of FORT BEND COUNTY

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CHILD ADVOCATES of FORT BEND COUNTY Powered By Docstoc
					                General Requirements of All Child Advocate Volunteers
      Must be a minimum of 21 years of age
      Must complete the required volunteer interview & training course with AACASA staff
      Consent to a background check of felony records & child abuse registry
      Commit to serve for a minimum of one year.
      Complete the volunteer application & related forms including Pledge of Confidentiality
      Attend a minimum of 12 hours of in-service training per year (many offered throughout the
       year by AACASA)

                              Qualifications of AACASA Volunteers
    Willingness to work within the guidelines, policies, and standards of AACASA.
    Good human relations skills and the willingness & ability to be objective.
    Commitment of time, interest, and energy necessary to fulfill responsibilities of volunteer
     position.
    Willingness to accept guidance and direction.
    Sensitivity towards cultural / ethnic / religious / etc. differences.
    Ability to formulate and maintain an independent position throughout the assignment.
    Ability to communicate both verbally and in writing.
    Understanding of confidentiality and the personal commitment to maintain that confidentiality
     at all times.
    Able to provide your own (licensed & insured) transportation.

                                          PERMISSION FORM
I hereby give permission to Amarillo Area CASA, Inc. to inquire about my qualifications and/or character. I
understand this reference check may be made by phone or in writing, and will include present and past
employers, volunteer organizations and personal references.

I agree to clearance by any police department and Texas Department of Family & Protective Services /
Children’s Protective Services (CPS) check, and an online nation wide criminal history check through
VolunteerSelect.com.

Applicant’s Date of Birth:

Applicant’s Social Security Number:

Years residing in Texas / dates:

Additional states of residence / years there:



Maiden Name:

Any other names Applicant has used:




Signature of Volunteer Applicant                                     Date
                                            P.O. Box 691 Amarillo TX 79105
                                       (806)373-2272 Phone (806)373-3332 Fax
                                           melanie@amarillocasa.org Email
                                                                               AACASA VOLUNTEER APPLICATION – page: 1
                 CRIMINAL BACKGROUND HISTORY SCREENING
                       CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK
                            AUTHORIZATION/WAIVER/INDEMNITY
Each staff member or volunteer who is to be screened must sign an
authorization/waiver/indemnity form, giving approval for the Agency to perform the
criminal background search.
I HEREBY GIVE MY PERMISSION IN EXCHANGE FOR GOOD AND VALUABLE CONSIDERATION FOR
AMARILLO AREA CASA, INC. TO OBTAIN INFORMATION RELATING TO MY CRIMINAL HISTORY
RECORD THROUGH AMARILLO POLICE DEPARTMENT, TEXAS DEPARTMENT OF PUBLIC SAFETY,
TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES & VOLUNTEERSELECT.COM. THE
CRIMINAL HISTORY RECORD, AS RECEIVED FROM THE REPORTING AGENCIES, MAY INCLUDE
ARREST AND CONVICTION DATA AS WELL AS PLEA BARGAINS AND DEFERRED ADJUDICATION. I
UNDERSTAND THAT THIS INFORMATION WILL BE USED, IN PART, TO DETERMINE MY ELIGIBILITY
FOR AN EMPLOYMENT/VOLUNTEER POSITION WITH THIS ORGANIZATION. I ALSO UNDERSTAND
THAT AS LONG AS I REMAIN AN EMPLOYEE OR VOLUNTEER HERE, THE CRIMINAL HISTORY
RECORDS CHECK MAY BE REPEATED AT ANY TIME. I UNDERSTAND THAT I WILL HAVE AN
OPPORTUNITY TO REVIEW THE CRIMINAL HISTORY AND A PROCEDURE IS AVAILABLE FOR
CLARIFICATION, IF I DISPUTE THE RECORD AS RECEIVED.
I, THE UNDERSIGNED, DO, FOR MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, HEREBY
REMISE, RELEASE AND FOREVER DISCHARGE AND AGREE TO INDEMNIFY HOLD HARMLESS, AND
DEFEND AMARILLO AREA CASA, INC. AND EACH OF THEIR OFFICERS, DIRECTORS, EMPLOYEES,
AND AGENTS FROM AND AGAINST ANY AND ALL CAUSES OF ACTIONS, SUITS, LIABILITIES, COSTS,
DEBTS AND SUMS OF MONEY, CLAIMS AND DEMANDS WHATSOEVER, AND ANY AND ALL RELATED
ATTORNEY’S FEES, COURT COSTS, AND OTHER EXPENSES RESULTING FROM THE INVESTIGATION
OF MY BACKGROUND IN CONNECTION WITH MY APPLICATION TO BECOME A VOLUNTEER/STAFF
MEMBER. THIS INDEMNIFICATION DOES NOT INCLUDE ANY GROSS NEGLIGENCE OR INTENTIONAL
TORTIOUS CONDUCT ON THE PART OF AMARILLO AREA CASA, INC.


___________________________________________________________________________
APPLICANT’S SIGNATURE                                DATE

_______________________________________       __________________________________
PRINTED NAME                                  SOCIAL SECURITY NUMBER

_______________________________________
DATE OF BIRTH


Ethnicity (please check one):
             Anglo        Black     Hispanic     Indian      (Asian)       (Other)

FELONY CONVICTION INFORMATION

                                     FELONY INFORMATION
I have read this form in its entirety, including the list of offenses below, and understand that the
information will be verified by Amarillo Area CASA, Inc., and that the inclusion of any false
information or the omission of any requested information is cause for my immediate dismissal by
Amarillo Area CASA, Inc.

VOLUNTEER APPLICANT LAST NAME:                             AACASA VOLUNTEER APPLICATION – page: 2
I agree to inform Amarillo Area CASA, Inc. if this information changes any time during my
employment or participation in any of the programs of Amarillo Area CASA, Inc.


Name (please print)


Signature of Employee or Volunteer                                            Date

I ACKNOWLEDGE THAT I HAVE BEEN INFORMED OF THE FOLLOWING:
A.      AACASA PROHIBITS VOLUNTEERS FROM SERVING (unless discretion from Texas Casa’s rehabilitative
policies are used in accordance to a misdemeanor that does not involve children) in any capacity as an employee
or volunteer of a child-related / child-focused agency for any person convicted within the previous 10 years
(minimum) of:

       1.         Any felony or misdemeanor classified as an offense against person or family;
       2.         Any felony or misdemeanor involving public indecency;
       3.         Any felony violation of any statute intended to control the possession or distribution of any substance
                  included as a controlled substance in the Texas Controlled Substances Act.

            TITLE 5. CRIMES AGAINST THE PERSON   TITLE 6. OFFENSES AGAINST THE FAMILY   TITLE 43. PUBLIC INDECENCY
            Murder                               Bigamy                                 Prostitution
            Capital Murder                       Incest                                 Promotion of Prostitution
            Voluntary Manslaughter               Interference with Child Custody        Aggravated Promotion of Prostitution
            Involuntary Manslaughter             Enticing a Child                       Compelling Prostitution
            Criminally Negligent Homicide        Criminal Nonsupport                    Obscene Display or Distribution
            False Imprisonment                   Sale or Purchase of a Child            Obscenity
            Kidnapping                           Solicitation of a Child                Sale, Distribution, or Display or Harmful
            Aggravated Kidnapping                Harboring a Runaway Child              Material to a Minor
            Aggravated Rape                      Violation of a Court Order             Sexual Performance by a Child
            Sexual Abuse
            Aggravated Sexual Abuse
            Public Lewdness
            Indecent Exposure
            Rape of a Child
            Sexual Abuse of a Child
            Indecency with a Child
            Assault
            Aggravated Assault
            Deadly Assault on a Peace Officer
            Injury to a Child
            Reckless Conduct
            Terroristic Threat
            Aiding Suicide
            Tampering with Consumer Products


B.     CASA WILL REASSIGN OR REMOVE FROM CONTACT WITH CHILDREN OF ANY EMPLOYEE OR VOLUNTEER WITH A CHILD-
       RELATED / CHILD-FOCUSSED AGENCY FOR ANY OF THE FOLLOWING REASONS:
       1.     An indictment alleging commission of a felony classified as offense against the person or family, or of public
              indecency, or of a felony violation of any statute intended to control the possession or distribution of any
              substance included as a controlled substance in the Texas Controlled Substances Act;
       2.     An indictment alleging commission of a misdemeanor classified as an offense against the person or family or
              of public indecency;
       3.         An official criminal complaint accepted by a district or county attorney alleging commission of a
                  misdemeanor classified as an offense against the person or family or of public indecency.


     You must disclose any convictions preceding the date of this application of
     a felony or a misdemeanor within the prohibited class or any felony
     violation of any statute intended to control the possession or distribution of


VOLUNTEER APPLICANT LAST NAME:                                                AACASA VOLUNTEER APPLICATION – page: 3
   any substance included as a controlled substance in the Texas Controlled
   Substances Act.
        If you HAVE been convicted, please give details below:
           DATE       OFFENSE / NATURE         LOCATION             DETAILS & DISPOSITION
                       OF CONVICTION




   I,                                                                                             ,
                                                Print Name
           am
           am not
   currently under indictment or charged in an official criminal complaint accepted by a district or
   county attorney with a felony or misdemeanor within the prohibited class.

        If your answer yes (i.e.: you ARE under indictment), please give details below:
           DATE           CHARGES            LOCATION                     DETAILS




VOLUNTEER APPLICANT LAST NAME:                               AACASA VOLUNTEER APPLICATION – page: 4
                                   PRIVATE INFORMATION POLICY
                                               Amarillo Area CASA, Inc.

SYSTEM NAME: Volunteer Files.

SYSTEM LOCATION: Volunteer files are maintained in the Volunteer Coordinator office at Amarillo Area CASA, Inc.
headquarters.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM: Individuals covered by this system include persons
who have applied to be CASAS, are current and past CASAS, and have been terminated from the AACASA program.

CATEGORIES OF RECORDS IN THE SYSTEM: Volunteer files consist of a variety of records maintained by operating
officials to administer personnel matters affecting volunteers. Records may include: applications for volunteer service,
registration forms, background checks, other administrative forms, correspondence, resumes, letters of recommendation,
college transcripts and forms, performance assessments, and a signed case acceptance. Volunteer files may include some
or all of the following information about an individual: name; home and emergency addresses and telephone numbers;
social security number; birth date; professional qualifications, training, awards, and other recognition; employment
history; and information about injuries, conduct, attendance, years of service, criminal history, and child protective
services history.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE
PURPOSES OF SUCH USES: AACASA maintains volunteer files on individuals to: evaluate individuals who apply to serve
as volunteers, advocates, and interns at AACASA facilities; assign work and monitor performance; and carry out personnel
management responsibilities in general affecting those volunteers. AACASA may disclose attendance and performance
information on interns and work study students to colleges and universities that oversee those individuals in student
internships and work study programs.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF
RECORDS IN THE SYSTEM:

STORAGE: Paper and electronic records.

RETRIEVABILITY: Information in volunteer files may be retrieved primarily by the name of the individual.

SAFEGUARDS: During business hours, paper records are maintained in areas accessible only to the Volunteer
Coordinator and are locked. Electronic records are accessible via passwords from terminals located in attended offices and
are protected by firewalls and other security measures. After business hours AACASA offices are locked, the building is
locked, and entrances are monitored by electronic surveillance equipment, also allowing only keycard access after
business hours.

RETENTION AND DISPOSAL: Volunteer files are destroyed in accordance with the disposition instructions in AACASA
Maintenance and Records Disposition Manual. Individuals may request a copy of the disposition instructions from the
Volunteer Coordinator.

NOTIFICATION PROCEDURE: Individuals interested in inquiring about their records should notify the Volunteer
Coordinator at AACASA PO Box 691 Amarillo, TX 79105.

RECORD ACCESS PROCEDURES: Individuals who wish to gain access to their records should submit their request in
writing to the Volunteer Coordinator at AACASA PO Box 691 Amarillo, TX 79105.

RECORD SOURCE CATEGORIES: Information in volunteer files is obtained from the volunteers themselves, persons
listed as references in applications submitted by volunteers, and educational institutions.
I have reviewed and understand the Private Information Policy and agree to comply with it:


Name (please print)


VOLUNTEER APPLICANT LAST NAME:                                           AACASA VOLUNTEER APPLICATION – page: 5
Signature                                                                      Date




                                          Equal Opportunity Volunteer

       CASA is an Equal Opportunity Volunteer Organization. Accordingly we promote equal opportunity in
the areas of volunteer recruitment, training and development. Our volunteer practices are without regard to
race, national origin, religion, sex, age, sexual orientation, disability, medical condition or veteran status and all
other categories protected by federal, state and local anti-discrimination laws.



CASA may complete a background check every three years as long as I am a CASA volunteer.




Signature: ___________________________                         Date: ___________________




VOLUNTEER APPLICANT LAST NAME:                                         AACASA VOLUNTEER APPLICATION – page: 6
                                                                            N

                                                                  W                          E



                                                                                  S




       CASA                  Marriot
                                       Acapulco
                                       Restaurant




VOLUNTEER APPLICANT LAST NAME:                      AACASA VOLUNTEER APPLICATION – page: 7

				
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posted:11/14/2011
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