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KENNEWICK PARKS AND RECREATION 2901 Southridge Blvd., Kennewick, WA 99338 PHONE: (509) 585-4293 E-MAIL: [EMAIL REDACTED] Volunteer Application Form Full Name: Address: City/State/ZIP: Day Phone: Cell: Availability: Hours/days available? Su M T W Th F Sa AM PM On-going On-call (Please circle) Male Female Birth Date: *Age: (*Minors 17 and younger must be supervised by an adult and have written consent of a parent or legal guardian prior to volunteering) Emergency Contact Name Phone Number: Emergency Contact Name Phone Number: Do you currently volunteer? Yes No If “yes”, where do you volunteer: List the type of volunteer work you do: Name of Supervisor you report to when volunteering: Supervisor’s Day Phone: Volunteer Interests: Youth Sports Youth Activities Special Event(s) Day Camp Office Work/Clerical Kitchen Assistance Newsletter Folding and/or Mail Preparation Adult or Senior Programs Other: List any skills, coaching/playing experience that you may have: (For example: typing, working w/the public, teaching a craft/class, computer skills, foreign languages, coaching and/or playing a sport, event planning, kitchen experience, etc.) Have you been convicted of a crime by a court of law within the last 10 years? Yes No (A conviction will not necessarily bar you from volunteering.) Please list two personal references who can speak knowledgeably of your ability to volunteer: NAME ADDRESS TELEPHONE OCCUPATION YEARS KNOWN I understand that all information on this form is voluntarily supplied and may be disclosed for volunteerism purposes only. I hereby volunteer my services and understand that I am not a paid employee of Kennewick Recreation and Community Services or the City of Kennewick. I agree to keep all information about clients, volunteers, or other individuals, obtained while volunteering, confidential. I realize and understand that there are certain risks inherent in the activity for which I am volunteering for. Also, I agree to hold the city of Kennewick, Pasco, Richland, all school districts, and any employee or volunteer associated with the program I am involved in harmless from, and indemnify them for, any damage or loss arising as a result of my (my child’s) participation. I give permission to have my (my child’s) photo taken during this program and used for publicity purposes by the City of Kennewick. I hereby give my consent for emergency medical treatment. I understand that this is to prevent undue delay and assure prompt treatment and that only a licensed healthcare provider will be engaged for such an emergency. Volunteer Signature (or Parent/Guardian for a minor) Date Signed **In addition, complete the attached Authority for Release of Information form and return both forms to Kennewick Parks & Recreation, 2901 Southridge Blvd., Kennewick, WA 99338 H/Parks/Division Public/Volunteers/Volunteer Application Form 2013 ---PAGE BREAK--- FOR OFFICE USE ONLY: Talentwise Clear___ Alert___ KPD Cleared___ Denied___ Advise CA___ KPD Rep. Initials Date When check is complete, please return to Christy in the City Attorney’s Office. Thank you! For Office Use Only: Hired Staff ______Volunteer______Team Coach_____ Asst. Coach_____ Previous Hire/Volunteer AUTHORITY FOR RELEASE OF INFORMATION I, ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ , authorize and give consent to the City of Kennewick to obtain information about me, including the following: Criminal background records/information Sex Offender registry checks Address Social Security Number/Birth Date I hereby authorize consumer reporting agency, Talentwise, or any law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, record/data repositories, courts (federal/state/local), motor vehicle record agencies, my past or present employers, the military, and other individuals or sources to furnish any and all information on me that is requested by the City of Kennewick By my signature (including electronic) below, I certify the information provided on and in connection with this form is true, accurate, and complete. I agree that this form in original, faxed, photocopied or electronic form will be valid for any background reports that may be requested by or on behalf of the City of Kennewick. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. This release is binding until revoked in writing. Please Complete All Sections: (If in writing, please print legibly) Full Name ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ (First Name) (Full Middle Name) (Last Name) Previous Names/Maiden Name ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Current Address ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ City/State/Zip: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Telephone # ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Date of Birthͺͺͺͺͺͺͺͺͺͺͺͺͺͺ {ocial Security # ͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Signature ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ 5ĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ---PAGE BREAK--- 2 Volunteer Screening Policy CITY OF KENNEWICK PARKS AND RECREATION DEPARTMENT Volunteer Screening Policy Description In order to preserve the safety and wellbeing of participants in its youth and vulnerable adult programs and events, the Kennewick Parks and Recreation Department has selected TalentWise and the Kennewick Police Department to conduct background checks on all volunteer coaches for youth athletic programs and certain other programs and events involving youth and vulnerable adults. Volunteers will be required to sign an authorization form which will provide date of birth, Social Security Number, and current address, authorizing the Kennewick Parks and Recreation Department to order an individual criminal background check. All authorization forms and results of screening must be received prior to the start of volunteer duties. This policy will include all volunteers who work with youth, vulnerable adults, and who those wish to be named a coach that may, in the course of their volunteer service, have the opportunity to be alone with children or vulnerable adults during activities scheduled for Kennewick Parks and Recreation sponsored programs. The Kennewick Parks and Recreation Department reserves the right to conduct background checks of all volunteers working programs/events involving children and vulnerable adults. TalentWise and the Kennewick Police Department will conduct the background checks on volunteers. All information received as a result of the screening will be kept confidential and not disclosed to anyone outside the City of Kennewick organization. All authorization forms, records or reports shall be maintained in a confidential manner, and kept for a fixed period of time as set by the City’s record retention policy. If any disqualifying information is found that prevents an applicant from being accepted, the City Attorney’s Office will be responsible for notifying applicant of disqualification. In the event the applicant feels their criminal background check contains inaccurate information, it is the applicant’s responsibility to contact the reporting agency (TalentWise, police departments, courts) and resolve any issues. Kennewick Parks and Recreation and its employees are not responsible for errors or omissions that may be reported on background checks. Frequency of Background Investigations Background investigations will be conducted annually for all volunteer youth coaches and other volunteers for certain programs and events as deemed necessary. Only one background check is necessary per year regardless of the number of different sensitive positions a volunteer may fill during any year. The initial authorization release signed by the volunteer applicant specifically states that the release shall remain in effect until revoked in writing. ---PAGE BREAK--- 3 Volunteer Screening Policy Criteria for Exclusion Disqualifying Factors A person will be disqualified and prohibited from serving as a volunteer if the person has been found guilty of any of the following crimes or has pending charges as identified below: (Guilty means that a person was found guilty following a trial, entered a guilty plea, entered a no contest plea accompanied by a court finding of guilty, regardless of whether there was an adjudication of guilt (conviction) or a withholding of guilt. This recommendation does not apply if criminal charges resulted in acquittal, Nolle Prosse, or dismissal.) DISQUALIFICATION BASED ON OFFENSE: SEX OFFENSES All Sex Offenses – Regardless of the amount of time since offense. Examples include: child molestation, rape, sexual assault, sexual battery, sodomy, prostitution, solicitation, indecent exposure, etc. FELONIES All Violent Felonies – Regardless of the amount of time since offense. Examples include: murder, manslaughter, aggravated assault, kidnapping, robbery, aggravated burglary, child endangerment etc. All Felony offenses other than violent or sex offenses within the past 10 years. Examples include: drug offenses, theft, embezzlement, fraud, etc. MISDEMEANORS All misdemeanor violent offenses involving a minor or vulnerable adult (unless the applicant was themselves a minor) – regardless of the amount of time since the offense. All misdemeanor drug & alcohol offenses involving a minor or vulnerable adult (unless the applicant was themselves a minor) – regardless of the amount of time since the offense. All other misdemeanor violent offenses within the past 7 years. Examples include: simple assault, battery, domestic violence, hit and run, etc. All misdemeanor drug & alcohol offenses within the past 7 years or more than one offense in the past 10 years regardless of whether the offense involved a minor or a vulnerable adult. Examples include: driving under the influence, simple drug possession, drunk and disorderly, public intoxication, possession of drug paraphernalia, etc. Any other felony or misdemeanor within the past 7 years that would be considered a potential danger to vulnerable populations. Any felony or misdemeanor convictions for which individual accepted through plea bargaining or other legal action a lesser plea conviction than that original charge that involved any of the above listed offenses. ---PAGE BREAK--- 4 Volunteer Screening Policy Any felony or misdemeanor conviction or pending charges which involve a crime against a member of the vulnerable population or pending charges of felonies or misdemeanors as listed within this procedure. PENDING CASES Any applicant who has been charged with any of the disqualifying offenses will not be allowed to volunteer until disposition of the charge. A serving volunteer who has been charged with any of the disqualifying offenses will have their service suspended until disposition of the charge. A volunteer must immediately inform the Kennewick Parks and Recreation Department of any charge(s) that has been filed against the volunteer and which, if convicted, would cause them to be disqualified as a volunteer as stated in this policy. Failure to do so may result in further penalties including permanent disqualification. The Background Check Process is an ongoing process and is subject to review and changes as determined necessary by the City of Kennewick in administering its volunteer programs.