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NCFAN |
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NCFAN |
Volunteer Application
Form
(Note: Please complte form, read conficentiality
agreement, sign it & and mail it to NCFAN, attention
Volunteer Coordinator
Date: ________
Name: __________________________________________________________________
Address: _________________________________________________________________
Home Phone: ________________________ Work Phone: __________________________
Fax: ______________ Pager: _______________ Email: ____________________________
Birth Date: _____________ Referred by :_________________________________________
Drivers License # _____________________________
In case of emergency, please notify:
Name: __________________________________________________________________
Address: _________________________________________________________________
Home Phone: ________________________ Relationship: __________________________
Personal Reference:
Name: __________________________________________________________________
Address: _________________________________________________________________
Home Phone: ________________________ Relationship: __________________________
Work Background Information:
Business/Organization: __________________________ Position: ______________________
Address: __________________________________________________________________
Phone: _______________________________ Supervisor's Name: _____________________
School: _______________________ Year: __________ Major: _______________________
Interests (circle all that apply)
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| Administration/office/clerical | Public Relations | Client Services/Case Management |
Day time phone line |
Flyer Distribution |
Buddy Program |
If you have an interest in Education (trained educators/counselors, HIV positive speakers, prevention/outreach, events/health fairs. table representatives/support), please contact NCFAN to receive a separate application form.
List the top three choices of interest, in order of preference: _____________________________
__________________________________________________________________________
Please list any special skills or interests: ____________________________________________
__________________________________________________________________________
Why do you wish to volunteer: __________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Time/Day(s) of availability: ______________________________________________________
Contract Agreement:
I agree:
To attend orination and training sessions as required by the Network, and to undertake continuing education as provided to maintain competence as a volunteer.
To volunteer with a professional positive spirit and to be responsible for reliable and prompt attendance when scheduled.
To personally consult with coordinators to seek assistance or guidance when assuming a new task or responsibility.
To work with Network staff and abide by the policy and decisions of the Executive Director, Executive Board, and Board of Directors.
To sign the Release of Liability and the Conficentiality Agreement.
Release of Liability Agreement:
As consideration for being permitted by NCFAN to participate in these activities and the use of their facilities, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make claim against, sue, or attach the property of NCFAN for injury or damage resulting from the negligence or other acts, how-so-ever caused, by any employee, agent, or volunteer contractor of NCFAN as a result of my participation as a Volunteer. I hereby release NCFAN from all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or may hereafter have for inujury or damage resulting from my participation as a Volunteer.
Confidentiality Agreement:
I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and North Central Florida AIDS Network (NCFAN) and sign it on my own free will, and undersigned, acknowledge that the unauthroized disclosure of any information designated as confidential violates clients and NCFAN's right to privacy, and do recognize my responsibility to hold information in strict confidence. The violation of confidence may cause my immediate termination as a volunteer of the Network and may be cause for possible legal action against me.
Signature of Volunteer: ________________________________ Date: __________________
Witnessed by: ______________________________________ Date: ___________________
To be completed by NCFAN Staff: Volunteer Coodrinator,
NCFAN _____________________________ Date: ______________ |
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