General Information
* Email:
Birth Day:
01
02
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06
07
08
09
10
11
12
13
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15
16
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19
20
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31
Birth Month:
January
February
March
April
May
June
July
August
September
October
November
December
Work Information
Emergency Contact Information
Areas of Interest
Availablity Days/Hours
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Weekend:
Racial Origin
Racial Origin
Volunteer Agreement
Thank you for your interest in volunteering. Please read and accept the volunteer agreement below.
As a Volunteer I agree:
To read the Volunteer Manual (provided during training).
To notify GCKH at least 24 hours before I am unable to work my scheduled shift.
To notify GCHK at least 2 weeks prior to separation from GCKH.
To be courteous and professional. (Volunteers represent GCKH to our families and the public. If you have a problem or concern, be sure to discuss it with the Executive Director.)
To respect the privacy of each visitor/donor/family by keeping their information (personal & business) confidential.
GCKH families and guests are never to be transported in personal vehicles and I will not open my home to GCKH guests or families as a place to stay.
To seek the assistance of staff on duty in any situation requiring special guidance.
To refer all media inquiries to the Executive Director for comments.
To withhold personal medication from family members, staff or other volunteers. (I understand it could negate the GCKH insurance policy and make the House liable for adverse reactions).
* You must read and accept the Volunteer Agreement
Grant, Assignment, Release and Waiver
I hereby grant to Gulf Coast Kid’s House (GCKH) and programs, advertising and promotional agencies, and their agents (collectively, “GCKH”), the irrevocable, unrestricted right to use, publish, display and distribute materials bearing my name, voice, likeness or any other identifiable representation of myself. These materials may appear in any form, style, color or medium whatsoever now or hereafter known (including, without limitation, photographs, videotapes, films, sound recordings, software, drawings, prints, broadcast, internet and electronic media).
I agree that all materials containing any identifiable representation of me (including, without limitation, all negatives, plates and masters of any photographs, files, prints or tapes) shall be and remain the sole and exclusive property of GCKH, and I hereby assign any proprietary right I may have acquired in or to such material to GCKH. I hereby release and forever discharge GCKH from any and all liability and damages relating to the use of my name, voice, likeness or any other identifiable representation of me.
I hereby waive any right I may have to inspect or approve the finished materials or any part or element thereof that incorporates my name, voice, likeness or any other identifiable representation of myself.
I have agreed to the above in consideration of the opportunity given to me by GCKH to appear in these materials. I acknowledge that I have fully read and understand this document and that I have had any questions regarding its effect or the meaning of its terms answered to my satisfaction. I certify that I am at least 18 years of age, unless this document is also signed by my parent or legal guardian.
I affirm the information provided on this application is true and complete. I agree to conform to all policies and regulations as stated by The Gulf Coast Kid’s House. I understand that by signing this form I am giving permission for a security check including but not limited to a criminal background check with any State agency, Federal agency, or any other appropriate agency. I understand that this application does not guarantee a volunteer placement. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my privilege to volunteer being revoked.
* You must accept all Grant, Assignment, Release and Waiver
* Electronic Signature:Hold Harmless Agreement
Whereas, GCKH is non-profit corporation incorporated under the laws of Florida;
Whereas, GCKH provides a facility for families with alleged child maltreatment;
Whereas, the facilities maintained by GCKH may have members of the public, some who are accused of committing crimes, located on the premises;
Whereas, GCKH participates in various fund raising activates within Florida; and
Whereas, Volunteer desires to volunteer for GCKH;
Now therefore, in consideration of being permitted to become a GCKH volunteer, Volunteer hereby agrees that their services shall be undertaken by Volunteer at their own risk and responsibility, and the GCKH shall not be liable to Volunteer for any claims, demands, injuries, damages, actions or causes of action which may arise from Volunteer’s volunteer services whether said claims, demands, injuries, damages, actions or causes of action arise from negligence or otherwise, on the part of GCKH, its employees, agents, other volunteers, or third parties.
* Electronic Signature:Conflict of Interest Disclosure and Confidentiality Statement
During the time that I serve as a volunteer /professional within Gulf Coast Kid’s House, I realize that I will gain access to information that is considered to be confidential and/or proprietary. Such information relates to families, donors, strategic planning and initiatives, submitted proposals, criteria or decisions made with regard to the business of Gulf Coast Kid’s House.
Since confidential and proprietary information is crucial to the operation of the Organization, and because GCKH has the obligation to protect such information, I agree that I will not use, publish or disclose such information during or subsequent to my time employment/involvement, and that I will preserve the restricted nature of this information except to the extent that it becomes publicly available, or is otherwise lawfully obtained outside the scope of this agreement from third parties.
Confidential information includes but is not limited to:
Case information about the children and families GCKH serves.
Client records, tapes (video/audio) and team’s decision made relative to specific cases.
Donor information
Volunteer Background Checks.
By signing this Confidentiality Acknowledgement, you acknowledge that:
I am obligated to hold confidential information in the strictest confidence and not to disclose the information to any person or in any manner, which is inconsistent with applicable policies and procedures of GCKH.
Your confidentiality obligation shall continue indefinitely, including at all times after your association w/GCKH.
Impermissible disclosure of confidential information about a person may result in legal actions being taken against you, by or on behalf of that person.
I will not duplicate any material without express written permission from GCKH or the author of the material.
I will not teach or present any material without specific written approval from GCKH.
I will not remove any written or taped information or records from the offices of GCKH without the expressed permission from the Executive Director or designated professional staff.
During your time at GCKH, you may come in contact with someone that you know. If this happens please tell the Volunteer Coordinator (volunteers) and/or Executive Director (staff, interns, etc.) immediately.
Additionally, as a volunteer/professional, I realize that I have an obligation to disclose and eliminate (if necessary) any potential or actual duality of interest or conflict of interest.
Below, I have listed all community organizations, non-profit corporations or charitable programs that I, or a member of my immediate family have a relationship with, that have sought or may in the future seek to do business with GCKH. The term “relationship” means any relation with a person or organization, whether financial (such as a significant donation of more than $100), employment (such as a volunteer assignment, part-time job or as a consultant or independent contractor) or fiduciary (such as a board member or officer). The term “immediate family” means spouse, parent, children or other individual living in the same household.
Conflict Disclosure
I hereby certify that I have read, understand and agree to the Gulf Coast Kid’s House policies as described in this statement, with respect to confidential information and conflict of interest, and that the information given in this statement is complete and accurate to the best of my knowledge.
If you have any questions concerning the confidentiality or disclosure of information, you should contact the GCKH Executive Director.
* Electronic Signature: