Application Form - Lutheran Family Services Rocky Mountains - Colorado Springs, CO

Background Check Authorization (background check will be sent via email before you begin volunteering.

In view of my desire to volunteer for Lutheran Family Services of Colorado and in understanding of its role to protect the best interest of its clients, I, _______________________, hereby authorize the following:

(initial next to each line if completing on paper)

_______ A check of my criminal background, if any;

_______ A check of my name against sexual offender public registries.

I also waive any further authorization requirements and agree to release and hold harmless Lutheran Family Services of Colorado from any claims, liability, losses or damages that may arise from the request and usage of such information.

I certify that the statements made in this Volunteer Application are true and accurate to the best of my knowledge and have been given voluntarily. I understand that this information may be disclosed to any party with proper interest. I agree to:

• perform my duties to the best of my ability,
• respect the culture and integrity of the people with whom I work,
• adhere to the ethic of confidentiality,
• adhere to agency policies and procedures as explained to me,
• meet time commitments or make alternative arrangements,
• send in volunteer time sheets at least once a month.

AUTHORIZATION FOR RELEASE OF INFORMATION

            I, _____________________________, acknowledge that Lutheran Family Services Rocky Mountains (hereby LFSRM), with whom I am volunteering, or to whom I have submitted a volunteer application, has advised me that the information requested below concerning my background is required to assist the Company and LFSRM in making a determination to allow me to volunteer. The information developed and this document also may be used in determining my qualifications for future assignments and/or retention.

            I hereby authorize the Company, its agents, or designated representatives bearing this document, or a copy hereof, to obtain information relating to my employment and criminal history background from any law enforcement, criminal justice, or other government agencies, employers, ex-employers, and individual persons.  Any and all agencies, organizations, institutions, governmental bodies, companies or individuals are released from any liability for providing this information.

            Furthermore, I hereby release any individual of the Company to include, but not limited to, record custodians, directors, agents, employees or any other authorized representatives of the Company from any and all liability for damages of whatever kind and nature, which may at any time accrue to me on account of (1) reliance by such persons on the information submitted in my employment application; (2) reliance by such persons on the information obtained pursuant to this authorization; (3) compliance with, or any attempts to comply with, this authorization; and (4) termination of my volunteer assignment, if commenced, based upon information developed pursuant to this authorization.

            I hereby certify that all statements and answers set forth on my application are true and complete to the best of my knowledge, and I understand that subsequent to employment if any such statements and/or answers are found false or that information has been intentionally omitted, such false statements or omissions will be just cause for termination of my employment.

            I hereby certify that I have read and understand the foregoing.

Confidentiality Agreement

Lutheran Family Services – Refugee & Asylee Programs

People that have been displaced may have endured the loss of their home, way of life and dignity. They may have suffered immense tragedies with their families and be experiencing post traumatic stress. They have come to this community to rebuild their lives in keeping with their traditions and individual nature. They have a right to recover their privacy and to determine when and how their stories might be shared with others.

Volunteers who work with this program agree to:

1. Respect the privacy of people with whom you work as the stories they share with you aren’t intended to be shared with others. Assume that anything you learn about any of LFS’s clients is considered to be private information.
2. Safeguard the confidentiality of displaced people by not making their names, addresses, phone numbers or personal circumstances public in any fashion without consent of the client and Lutheran Family Services staff.
3. Hold in strict confidence any information of a sensitive nature you encounter while working, including anything shared by the Lutheran Family Services staff.
4. Notify Lutheran Family Services staff when problems, questions or issues arise, as LFS bears ultimate responsibility for all clients, and is best able to resolve the above most effectively.

I have read these policies and understand the displaced’s right to privacy and confidentiality.  I will fully abide by these policies. If I do not abide by this agreement, I may be asked to end the relationship with the clients and/or Lutheran Family Services.

Health risk acknowledgement

Lutheran Family Services – Refugee & Asylee Programs

People that have been displaced may have endured the loss of their home, way of life and dignity. They may have suffered immense tragedies within their families and be experiencing post traumatic stress. In addition, they come from a variety of places in the world with varying health standards and situations. As such, involvement with newly arrived refugees may involve a minimal amount of risk to one’s health.

Volunteers who work with this program understand that:

1. Lutheran Family Services and its volunteers are committed to and constrained by the Health Insurance Portability and Accountability Act (HIPPA) of 1996 and are therefore respectful of the privacy of each client’s health information.

2. Lutheran Family Services and others involved in refugee resettlement work diligently to protect public health and the health of volunteers. This includes advising volunteers not to meet with refugee clients until it can be reasonably determined that there are no discernable risks to the volunteer’s health.

3. Volunteers working with refugees might be exposed to health risks.