Volunteer Application Form

SECTION 1: Personal Information

Full Name *

First Name Last Name

Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email Address *

Phone Number *

- Area Code Phone Number

Date of Birth *

- Month - Day Year

Are you 18 years or older? *If no, please complete SECTION 7: Volunteer Release of Liability *

SECTION 2: Background Information

What type of work are you interested in?

With individuals/families (activities) Administrative/clerical support

When are you available for volunteer work?

Full time Part time Evenings/Weekends Option 4

What volunteer level would you be interested in?

Level 1 Level 2

Related work experience: (if none, why are you interested in working with individuals with developmental disabilities?)

Volunteer's special interests/skills/activities/hobbies:

Have you ever been convicted of a criminal offense, felony or misdemeanor? If yes, please state nature of offense(s), date(s), city and state. *Please note, Developmental Pathways cannot accommodate Court Ordered Community Service Hours for any reason. *

If yes, please explain.

SECTION 3: Emergency Contact Info

In case of emergency, please contact:

First Name Last Name

Phone Number:

- Area Code Phone Number

Relationship:

ex: mom, dad, etc.

SECTION 4: Releases

Volunteer Release of Liability Statement

I release Developmental Pathways, Inc., its employees, agents, leaders, instructors, contractors and volunteers from any liability for loss or injury to my person or property, which may occur due to my negligence, the negligence of Developmental Pathways, Inc., or any third parties, or other actions or omissions. This release applies to any losses or injuries which may occur as a result of, or during my participation in, volunteer services. This may include, but is not limited to, traveling in agency designated vehicles, working with individuals who may have mental or physical disabilities, participating in phyiscal labor and/or any other volunteer activities. I realize that this is a binding contract. I have read and understand this policy and knowingly and voluntarily sign below. I also acknowledge that I have been advised of the provisions of C.R.S. *13-21-117.5 which limits the civil liability of developmental disability service providers.

Applicant's Signature

Clear

Date

- Month - Day Year

SECTION 5: Releases (continued)

Confidentiality Policy

I understand that I will maintain confidentiality regarding any company or client information that is made known to me as a result of my volunteer work with Developmental Pathways. Specifically, this means that outside the agency, no information, incidents or stories will be related to anyone for any reason without a properly signed release of information and approval of Developmental Pathways. I understand that I may be removed from my volunteer position for violation of this policy. I also understand that the records and information pertaining to developmentally disabled persons or their families is strictly confidential and unauthorized disclosure is prohibited by C.R.S. *27-10.5-120.

Applicant's Signature

Clear

Date

- Month - Day Year

Parent's Signature (If under 18)

Clear

Date

- Month - Day Year

SECTION 6: Signatures

Applicant's Signature

I certifify that all the information provided is true and complete to the best of my knowlege. I realize that any misrepresentation in the information submitted or any intenionally withholding of essential information called for in this form may result in my application being rejected. I offer to volunteer my services to Developmental Pathways. I understand that I will not be paid in any way. I understand Developmental Pathways, Inc. reserves the right to dismiss volunteers for any reason.

Applicant's Signature

Clear

Date

- Month - Day Year

Parent's Signature (If under 18)

Clear

Date

- Month - Day Year

SECTION 7: Volunteer release of liability for participants under age of 18

All participants under the age of eighteen (18) must have this Release Form signed by their parent or guardian.

I release Developmental Pathways, Inc., its employees, agents, leaders, instructors, contractors and volunteers from any liability for loss of injury to my child or property, which may occur due to their negligence, the negligence of Developmental Pathways Inc., or any third parties, or other actions or omissions. This release applies to any losses or injuries which may occur as a result of, or during their participation in, volunteer services. This may include, but is not limited to, traveling in agency desginated vehicles, working with individuals who may have mental or physical disabilities, participating in physical labor and/or any other volunteer activities. I realize that this is a binding contract. I have read and understand this policy and knowingly and voluntarily sign below. I also acknowledge that I have been advised of the provisions of C.R.S. *13-21-117.5 which limits the civil liability of developmental disability service providers.

Minor's Name:

First Name Last Name

Minor's Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent's or Guardian's Name:

First Name Last Name

Parent or Guardian's Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I hereby release and waive my child's prospective claim for negligence pursuant to C.R.S. *13-22-107(3).

Parent's Signature

Clear

Date

- Month - Day Year

Application must be signed prior to participation in volunteer activites.