VOLUNTEERCOMMUNITY SERVICE COVER SHEET

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VOLUNTEERCOMMUNITY SERVICE COVER SHEET Powered By Docstoc
					              VOLUNTEER/COMMUNITY SERVICE COVER SHEET
                         and AGREEMENT

VOLUNTEER NAME: ________________________________________(Please print)
PHONE NUMBER: ______________________________
DATE: __________________ STORE LOCATION: ____________
COURT APPOINTED: YES          NO
DISTRICT COURT #: ______________
Number of hours: _______ Start date: _____________End date: ______________

If not court related, referral agency: _____________________________
(Example: Vincentian, Michigan Works, Church, school, ROSS, JET, etc.)

The following documents must be attached:

Court Appointed Community Service Clients:
              Court Document(s)
              Current ID (Drivers License or Michigan State ID)
              Agreement (signed and dated)
              Application /Authorization for Background check & Waiver (signed and dated)
              Signed Policy and Dress Code

Non-Court Appointed Community Service Clients:
             Current ID (Drivers License or Michigan State ID)
             Agreement (signed and dated)
             Application/Authorization for Background check & Waiver (signed and dated)
             Signed Policy and Dress Code

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                                       AGREEMENT
AGENCY: We, the Society of St. Vincent de Paul, agree to accept the services of

___________________________________________ and we commit to the following:
       1. To provide accurate information, training and assistance.
       2. To ensure supervision and provide job assessment feedback.
       3. To respect the skills and individual needs of the volunteer.

VOLUNTEER: I, _________________________________________, agree to serve as a volunteer
and commit to the following:
       1. To perform volunteer duties as assigned to the best of my ability.
       2. To adhere to agency rules, policies and procedures, including record-keeping
          requirements and confidentiality of agency and client information.
       3. To meet time and duty commitments, or to provide adequate notice so alternate
          arrangements can be made.
                                 SIGNATURES REQUIRED:

VOLUNTEER:____________________________________ DATE: ____________________

STAFF REPRESENTATIVE: ________________________________DATE: _____________


                                                                                     (1)
VOLUNTEER APPLICATION /AUTHORIZATION FOR BACKGROUND
     CHECK & WAIVER FOR the Society of St. Vincent de Paul

NAME: __________________________________________________________
      (LAST)                        (FIRST)
DATE OF BIRTH: ____________________________ (MO/DAY/YEAR)

ADDRESS: _________________________________________CITY/ZIP __________

PHONE NUMBER: ___________________________

EMAIL ADDRESS: _______________________________________________

DRIVER’S LICENSE NUMBER: ____________________________________

   (By signing below, I specifically authorize Society of St. Vincent de Paul, its agents and its
employees to make inquiries of courts, law enforcement agencies and other entities for records of
criminal convictions. I understand that it is the intent of the Society of St. Vincent de Paul to deny
participation to any person who has been involved in or convicted of a criminal activity that may be
harmful to the Society of St. Vincent de Paul, the activity or the participants.)

SIGNATURE: ______________________________________DATE: _______________

       Society of St. Vincent de Paul ADULT VOLUNTEER WAIVER of
                                   LIABILITY
   I hereby acknowledge and accept that there are inherent risks involved in volunteer work. In
consideration of this acknowledgement and my voluntary participation in activities relating to
volunteering for the Society of St. Vincent de Paul, having read this waiver and understanding the
risks involved in participating as a volunteer for the Society of St. Vincent de Paul and the
agreement by the Society of St. Vincent de Paul to allow me to participate as a volunteer.
   I hereby release, on behalf of myself, and my successors, heirs, assigns, executors and
administrators, the Society of St. Vincent de Paul, its officers, directors, members and volunteers
from any claims of liability or demand whatsoever, including but not limited to bodily injury,
sickness, disease, death, property loss or damage, or any other loss or damage of any kind which
may arise out of or in connection to my participation in the Society of St. Vincent de Paul volunteer
activities, whether resulting from negligence or from some other cause.
   I have read and understand the forgoing Waiver of Liability, and by signing below, I indicate my
agreement. It is my intent to be legally restrained from asserting any claim connected herewith and
I understand that this agreement is unconditional and my not be waived by any person for any
reason whatsoever.
SIGNATURE:_____________________________________                     DATE: _______________

**If you are under 18, a parent/guardian must sign the waiver below:

    By signing below, I hereby waive and release the Society of St. Vincent de Paul together with all
of its agents, directors, employees, members and volunteers from any liability in the event I should
be injured while volunteering for the Society of St. Vincent de Paul.

__________________________________________________ ___________________
Parent/Guardian’s Signature                          Date
            Phone number: __________________________                                            (2)
            POLICY AND DRESS CODE FOR VOLUNTEERS

1. All items donated to the store immediately become store property. ABSOLUTELY, no
   items may be removed from the store or store dumpster without purchase, regardless of
   whether they have been priced. Taking any items without purchasing them is theft.
   Anyone caught stealing will be dismissed and not allowed to perform community service
   at the store in the future.
2. No working under the influence of alcohol or drugs. Anyone caught will be dismissed
   and the Probation department will be notified.
3. No music listening devices or cell phones or I pods allowed during work hours.
4. No offensive language.
5. DRESS POLICY is dressy casual—NO sandals, open toed shoes or blue jeans allowed.
   Anyone wearing jeans will be sent home.
6. Smoking is ONLY allowed 25 ft. away from the building and ONLY during scheduled
   breaks.
7. An 8-hour workday includes one 30 minute lunch and tow 15 minute breaks (one am and
   one pm) A 4 hour workday includes one 15 minute break.
8. Do not alter your time on your time sheet or you will be dismissed and your hours will be
   taken from you.
9. No standing around---keep busy or you will be sent home without credit of the time
   worked. There is ALWAYS something to be done!

I, the undersigned, have read and understand the above policy and dress code.

NAME: ___________________________________________
(PLEASE PRINT)

SIGNATURE: _______________________________________

DATE: _____________________

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The information below is designed to provide you with proper medical care in the event
of an emergency and is VOLUNTARY—completion below is OPTIONAL.

In case of emergency, notify: _____________________________________
Relation to Volunteer: ____________________________ Phone:__________________

Allergies/sensitivities: __________________________________________________

The information I have provided above is accurate. I understand and acknowledge that
this information will be made available to any employee who will assist me in the event
of an emergency.

SIGNATURE: _____________________________________________

PARENT/GUARDIAN: _________________________________________
(If volunteer is a minor)

DATE: ____________________________                                                   (3)