Personal Information
MINORS must complete this application with your Parent/Legal Guardian.

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* First Name

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* Last Name

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* Nickname

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* Date of Birth
We only ask for your date of birth for screening purposes. CHS is an equal employment opportunity employer that does not discriminate against qualified applicants or volunteers on the basis of race, sex, color, religion, age, marital status, national origin, handicap (disability), veteran status, sexual orientation, gender identity or as otherwise prohibited by the federal, state or local law.

Date of Birth

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* Address
Please list the current address for the city you wish to volunteer in.

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* Phone

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* Email

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* Emergency Contact Information

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* Take a picture of your Driver's License, State-Issued Photo ID or Passport and upload it here.
MINORS: You may upload an image of your Student ID only if you do not have a Driver's License, State-Issued Photo ID or Passport.

PDF, PNG, JPG, JPEG file types only.
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* ID/Passport State or Country of Issuance

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* ID/Passport Number
MINORS: If you do not have a Driver's License, State-Issued ID, or Passport, please provide your Student ID Number.

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* ID/Passport Expiration Date
MINORS: If you do not have a Driver's License, State-Issued ID, or Passport, please provide the date you will turn 18.

Date / Time
Education

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* Area(s) of Study

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* School(s)

Current Employment

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* Name of Employer

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* Position

Skills & Interests

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* Please identify if you are skilled in the following:

  Not applicable Skilled
Bicycle Assembly/Repair
CPR/First Aid
Doula (Birth Coach)
Event Planning
Hairstyling/Cosmetology
Handyman/woman
Nurse
Photography

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* Please identify your level of fluency for the following:

  Not Applicable Beginner Intermediate Advanced Fluent
Haitian Creole Fluency
Spanish Fluency

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* Are you interested in volunteering on an "on-call" basis?

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* Please list any previous volunteer experience.

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* Why do you want to volunteer for Children's Home Society of Florida?

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* Are you required to complete volunteer hours?

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* If yes, how many volunteer hours are you required to complete?

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* If yes, by what date will you need to have your volunteer hours completed?

Date
Background Information

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* Have you ever been convicted of, pled guilty or no contest (nolo contendre) to a crime?

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* If yes, please give details.
List ALL offense(s), date, place, disposition (outcome), penalty, etc.

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* Have you ever been charged with a crime and had adjudication withheld, or entered a pre-trial intervention/diversion program (i.e. community service)?

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* If yes, please give details.
List ALL offense(s), date, place, disposition (outcome), penalty, etc.

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* Have you ever been a defendant in a civil action for an intentional tort (including but not limited to assault, battery, infliction of emotional distress, etc.)?

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* If yes, please give details.
Case name, case number, court, date, nature of action, disposition (outcome), etc

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* Waiver and Release of All Claims
In consideration for me (or my underage child) being permitted to participate as a volunteer at Children’s Home Society of Florida, I, myself, my family, legal representatives, heirs and assigns, hereby release and hold harmless the Children’s Home Society of Florida, its officers, directors, employees and agents, from any claim, or cause of action, for personal injury, including death, and property damage whether caused by the active or passive negligence of the Children’s Home Society of Florida, its officers, directors, employees and agents, or from any other cause. I (or my underage child) expressly agree that this Waiver and Release of All Claims is intended to be as broad and inclusive as permitted by the laws of the State of Florida.

CHECKING "I AGREE" BELOW INDICATES THAT I HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.
MINORS: YOUR PARENT/LEGAL GUARDIAN SHOULD CHECK "I AGREE" BELOW TO INDICATE THAT THEY HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.

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* Confidentiality and Non-Disclosure Agreement
I understand I (or my underage child) am being utilized in a position of trust and in the course of my volunteering I (or my underage child) may have access to confidential information relating to Children’s Home Society of Florida, its clients and operations. I understand the need to keep this information confidential and the importance of not divulging this information to unauthorized individuals. I (or my underage child) am required to conduct myself in strict conformance with applicable laws and policy. I (or my underage child) will not access any confidential information unless I (or my underage child) have a need to know the information and have been authorized to receive the information in order to perform my assigned tasks. I (or my underage child) will not disclose any confidential information unless required to do so in the official capacity of my position. I (or my underage child) agree not to use the information in any way detrimental to the organization. I (or my underage child) agree that disclosure of confidential information is prohibited indefinitely, even after I (or my underage child) am no longer volunteering with CHS, unless specifically waived in writing by the authorized party. I (or my underage child) acknowledge that under the new Health Insurance Portability and Accountability Act (HIPAA) regulations, the consequences for violating this agreement are: discharge, loss of privileges, termination of volunteering ability, criminal prosecution, legal action for monetary damages or injunction, or both, or any other remedy available to CHS under the regulations. If you are a witness to or in any other way become aware of a violation of this policy, you (or my underage child) must immediately report this violation to your (or my underage child's) supervisor who, in turn, will notify the CHS Privacy Officer. If you (or my underage child) feel that you cannot discuss this matter with your supervisor, you (or my underage child) may notify the CHS Privacy Officer directly. HIPAA requires that all Children’s Home Society volunteers execute this Confidentiality and Non Disclosure Agreement.

CHECKING "I AGREE" BELOW INDICATES THAT I HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.
MINORS: YOUR PARENT/LEGAL GUARDIAN SHOULD CHECK "I AGREE" BELOW TO INDICATE THAT THEY HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.

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* Application Certification
I hereby certify all information listed on or uploaded to this volunteer application ("Information") is true and complete, and hereby authorize Children's Home Society of Florida ("CHS") to investigate said Information. I hereby understand any false, incomplete or misleading Information on this application or provided in the utilization process, discovered at any time, is sufficient cause for rejection of this application or removal from CHS's volunteer program. By volunteering for CHS, I (or my underage child) intend to perform service for charitable purposes and agree I (or my underage child) am not an employee of CHS and am not entitled to receive compensation for the time I (or my underage child) volunteer to CHS. If I (or my underage child) am accepted into the volunteer program, I understand such acceptance will be conditioned upon satisfactory results of a background investigation and ongoing compliance with such terms and conditions as CHS may from time to time require.

CHECKING "I AGREE" BELOW INDICATES THAT I HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.
MINORS: YOUR PARENT/LEGAL GUARDIAN SHOULD CHECK "I AGREE" BELOW TO INDICATE THAT THEY HAVE READ, UNDERSTAND, AND AGREE WITH THIS CERTIFICATION.

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