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NEXUSKIDS / COMPUTER BUDDIES PROGRAM
VOLUNTEER STATUS
Name __________________________________________________
Address ________________________________________________
City _______________________ State
_____ Zip Code _________
Phone Number ___________
Social Security Number ___________________________
Date of Birth_____________________________
Driver’s 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 workmen’s
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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