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Background Check

NEXUSKIDS / COMPUTER BUDDIES PROGRAM

VOLUNTEER STATUS

 

Name __________________________________________________

Address ________________________________________________

City _______________________ State _____ Zip Code _________

Phone Number ___________

Social Security Number ___________________________

Date of Birth_____________________________

Driverís License Number ___________________State of Issue___________

Expiration Date____________

Auto Insurance Company_________________________________________________________________

     (If you will be driving a privately owned vehicle to transport other volunteers or participants.)

I,____________________________________, have volunteered to serve as a 

_______________________

with the Nexuskids / Computer Buddies Program.  These duties consist generally of helping individual foster children master computer skills, encouraging the foster child to use the computer for schoolwork and improving academic achievement, and serving as a mentor for the foster child.

I understand that in operating my privately owned vehicle in support of Nexuskids / Computer Buddies, my automobile insurance coverage is the primary coverage.

 

I understand further that I am not an employee of Nexuskids / Computer Buddies; consequently I am not covered under any workmenís compensation coverage nor does Nexuskids / Computer Buddies provide any medical or liability insurance.

 

I have listed two persons not related to me as references.  These individuals have definite knowledge of my qualifications.

Name __________________________________________________

Address ________________________________________________

City _______________________ State _____ Zip Code _________

Phone Number ___________

Name __________________________________________________

Address ________________________________________________

City _______________________ State _____ Zip Code _________

Phone Number ___________

By my signature below I authorize the Nexuskids / Computer Buddies Program to contact these references and agree that any responses be confidential.

 

(This section MUST BE COMPLETED in accordance with DSS county policy (if Volunteer is handling money or working with children).  Further, I consent to a police records check.  (Yes/No) _______ (initials).  I have been informed of those factors which may constitute a disqualification.

 

HAVING BEEN INFORMED OF THE FOREGOING I DESIRE TO VOLUNTEER MY SERVICES ABOVE TO  NEXUSKIDS / COMPUTER BUDDIES PROGRAM.

Signature of Volunteer  _______________________________________________

Date ____________

Witness ___________________________________________________________

Date ____________                                                                        

DSS County use only

Reference Check:

Person Conducting Check _________________________

Satisfactory/Unsatisfactory __________________________

Date ____________                             

Police Records Check:

Person Conducting Check ____________________________

Qualified/Disqualified ____________________________   

Date ____________

Notification to Volunteer _________________________________

Person Making Notification _________________________________

Date __________

 

 

 

 

 

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Last modified: June 04, 2008