• Demographic Information

  • Please include full First, Middle and Last name.
  • (For background check purposes)
  • Emergency Contact

  • Internship Interest

  • Please attach.
  • Release of Information

    Please read the explanations below and check all boxes.
  • CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT:

    I understand the sensitive nature of information I may receive as a result of my Volunteer experience and agree to follow CICOA’s policy on the confidential nature of certain client information. I agree to sign a Confidentiality and Non-Disclosure Agreement.

    CRIMINAL BACKGROUND CHECK:

    *We require criminal background checks for all volunteers except those participating in seasonal group projects and Safe at Home. I understand that CICOA requires criminal history and/or driving record background checks for the purpose of evaluating me for a volunteer position. I understand that a background check is a consumer report which is covered under the Fair Credit Reporting Act. The consumer report may include the following areas: verification of social security number, criminal history records, and motor vehicle records to include traffic citations and registration. I hereby authorize CICOA to obtain a Consumer Report, to verify information that I have voluntarily supplied. This authorization and consent shall be valid in original, on-line, fax or copy form. I certify that the information contained on this form is true, correct and complete to the best of my knowledge. I also understand that any misrepresentation, falsification or omission of facts herein may be grounds for disqualification or separation.

    If a volunteer decision which adversely affects me is made based upon information obtained through a consumer report, I understand that I have the right to request a free copy of the report. If I dispute the information, I have the right to conclusively demonstrate the inaccuracy of the information.

    LIABILITY RELEASE:

    In consideration of the opportunity afforded me to participate in this Program, I hereby agree that I, my assignees, heirs, guardians, and legal representatives will not make a claim against CICOA Aging & In-Home Solutions, or any of its affiliated organizations, or either of their officers or directors collectively or individually, or the supplier of any materials or equipment that is used in the project, or any of the other volunteer workers, for the injury or death to me arising from my participation in the project. Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of actions resulting from personal injury or death to me sustained in connection with my participation in the project.

    PHOTO RELEASE:

    I certify that I am twenty-one years of age or over and hereby voluntarily and without compensation give CICOA Aging & In-Home Solutions (the organization), its successors and assigns and those acting under its permission or upon its authority, the unqualified right and permission to reproduce, publish, circulate or otherwise use my name and/or likeness of me in which I may be included in whole or in part. I waive any right to inspect and approve the finished product or copy that may be used or the use to which it may be applied. This authorization and release covers the use of said materials in any published or broadcast form and any medium of advertising or publicity.

    VOLUNTARY PARTICIPATION AND EXECUTION:

    I acknowledge that I have willingly agreed to serve as a volunteer for the CICOA Aging & In-Home Solutions Volunteer Program. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and CICOA Aging & In-Home Solutions, and I sign it of my own free will.