Volunteer Application Form

SECTION 1: Personal Information

Full Name*

First NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address*

Phone Number*

Area CodePhone Number

Date of Birth*

MonthDayYear

Are you 18 years or older? *If no, please obtain parent signature at the end of this form.*

SECTION 2: Background Information

What type of work are you interested in?

Activities/Events with individuals/familiesAdministrative/clerical supportSpecial Project SupportOther

When are you available for volunteer work?

Full timePart timeEvenings/WeekendsOther

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

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

*Please note, Developmental Pathways cannot accommodate Court Ordered Community Service Hours for any reason. 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. *

If yes, please explain.

SECTION 3: Emergency Contact Info

In case of emergency, please contact:

First NameLast Name

Phone Number:

Area CodePhone 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

Date

MonthDayYear

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

Date

MonthDayYear

Parent's Signature (If under 18)

Date

MonthDayYear

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

Date

MonthDayYear

Parent's Signature (If under 18)

Date

MonthDayYear

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 NameLast Name

Minor's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent's or Guardian's Name:

First NameLast Name

Parent or Guardian's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

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

Parent's Signature

Date

MonthDayYear

Application must be signed prior to participation in volunteer activites.