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Central Indiana - Volunteer Application & Waiver

 

Volunteer Application

1. Your information:

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Name:

 

 

   

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City/State/ZIP:

 

    

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Date of Birth:

 

 

 


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NOTE: Before answering this question regarding criminal convictions please refer to the instructions below if you reside or are applying for a position in Alaska, California, Connecticut, District of Columbia, Georgia, Hawaii, Massachusetts, Ohio or Washington.

A “yes” is not an automatic bar to volunteer service with the Susan G. KomenŽ Central Indiana ; the circumstances relating to the offense will be considered in relation to the volunteer position for which you are applying.  


INSTRUCTIONS FOR ANSWERING CRIMINAL CONVICTION INQUIRY


Alaska Applicants:  Do not identify convictions that are more than ten (10) years old.

California Applicants:  Do not identify convictions under California Health & Safety Code §§11357(b) or (c), 11360(b) (formerly subdivision (c) of section 11360), 11364, 11365, or 11550 related to marijuana offenses that occurred two or more years before the instant application.  Also, do not identify any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated, or any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.

Connecticut Applicants:  Applicants are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes.  Criminal records subject to erasure under these sections are records pertaining to a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an absolute pardon.  Any person whose criminal records have been erased pursuant to these sections is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.

District of Columbia
:  Do not identify convictions that are more than ten (10) years old.

Georgia Applicants
:  Do not identify any conviction that is considered a “first offender discharge.”

Hawaii Applicants
:  Do not answer this question at this time.  You will only have to answer this question if you receive a conditional offer to serve as a volunteer.  At that time you will be asked whether you have been convicted of a crime within the past ten (10) years.

Massachusetts Applicants
:  An applicant with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances, or convictions.  In addition, an applicant may answer “no record” with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.  Massachusetts applicants should not disclose information regarding first-time misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace.  Finally, Massachusetts applicants should not disclose convictions for other misdemeanors where the date of conviction or the end of any period of incarceration was more than five years ago unless there have been subsequent convictions within those five years.

Ohio Applicants:  Do not identify convictions that are more than ten (10) years old.

Washington Applicants
: Do not identify any conviction that is more than ten (10) years old at the time of making this application.

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Not Required - Please indicate if you have more than one year of experience in the following areas: (You may select multiple areas)

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Question - Not Required - How often would you like to volunteer?



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Emergency Contact:

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Information to Volunteer Applicants

(Read Carefully Before Signing)

You may be asked to sign an authorization for the Susan G. KomenŽ Central Indiana to fully investigate your suitability for volunteering (depending on the position and responsibilities) by obtaining information from your previous employers and/or other knowledgeable persons as to their firsthand experiences with you, and also, when deemed necessary, by obtaining reports from credit bureaus, credit agencies, or other consumer reporting agencies.  Under some circumstances, certain of such reports may be “consumer reports” or "investigative consumer reports" as to which, under the Fair Credit Reporting Act, you are entitled, upon your request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Susan G. KomenŽ Central Indiana .

 

Volunteer Applicant Statement

(Read Carefully Before Signing)

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation.  I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from the Susan G. KomenŽ Central Indiana .
If selected as a volunteer, I agree to comply with the rules and regulations of Susan G. KomenŽ Central Indiana .  
I also understand that smoking is prohibited in all indoor areas of the Susan G. KomenŽ Central Indiana .

 

Komen Volunteer Release

I wish to volunteer for the Indianapolis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. d/b/a Susan G. KomenŽ Central Indiana (“Komen Affiliate”).  I understand that my consent to these provisions is given in consideration for being permitted to volunteer for the Komen Affiliate.  I UNDERSTAND THAT THE NATURE OF VOLUNTEER ACTIVITIES THAT I MAY PERFORM IN MY CAPACITY AS A VOLUNTEER MAY INVOLVE PHYSICAL ACTIVITY, CONTACT WITH UNIDENTIFIED OR UNFAMILIAR PERSONS, OR OTHER POTENTIAL RISK OF BODILY INJURY OR DAMAGE TO PROPERTY AND I HEREBY VOLUNTARILY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR, AND THE RISK OF, ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE.  TO THE FULLEST EXTENT OF THE LAW, I, FOR MYSELF, MY NEXT OF KIN, MY HEIRS, ADMINISTRATORS, AND EXECUTORS (COLLECTIVELY, “RELEASORS”), HEREBY RELEASE AND HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST (I) THE KOMEN AFFILIATE, THE SUSAN G. KOMEN BREAST CANCER FOUNDATION, INC. D/B/A SUSAN G. KOMEN (“KOMEN HEADQUARTERS”), AND ALL OTHER AFFILIATES OF KOMEN HEADQUARTERS AND THEIR RESPECTIVE DIRECTORS, OFFICERS, VOLUNTEERS, AGENTS AND EMPLOYEES; AND (II) ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THE KOMEN AFFILIATE OR KOMEN HEADQUARTERS (COLLECTIVELY, THE “RELEASEES”) FOR ANY INJURY OR DAMAGES I MIGHT SUFFER IN CONNECTION WITH MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE.  THIS RELEASE APPLIES TO ANY AND ALL LOSS, LIABILITY, OR CLAIMS I OR MY RELEASORS MAY HAVE ARISING OUT OF MY VOLUNTEER WORK WITH THE KOMEN AFFILIATE, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SUCH LOSSES, LIABILITIES, OR CLAIMS BE CAUSED BY CONTACT WITH AND/OR THE ACTIONS OF OTHER PERSONS, CONTACT WITH FIXED OR NON-FIXED OBJECTS, NEGLIGENCE OF THE RELEASEES, RISKS NOT KNOWN TO ME OR NOT REASONABLY FORESEEABLE AT THIS TIME, OR OTHERWISE.

I understand that as a volunteer, I may become privy to confidential information about a Releasee. I agree to maintain the confidentiality of any information marked “confidential” as well as any information about each Releasee’s business operations, organizational structure, employee information, financial operations, marketing strategy, organization, donor lists and amounts, plans for upcoming events, current or proposed business transactions and sponsorships, and any proprietary information such as computer software and programming and the like that is not otherwise publicly disclosed.  I will not use any confidential information in any manner that would be detrimental to a Releasee.

At all times during my volunteer work with the Komen Affiliate, I will conduct myself in such a manner as not to reflect unfavorably on or in any way diminish the reputation of the Komen Affiliate, Komen Headquarters and its affiliates.  

I give my consent and permission to the Komen Affiliate, Komen Headquarters and its respective affiliates, successors, licensees, and assigns the irrevocable right to use, for any purpose whatsoever and without compensation, any photographs, videotapes, audiotapes, or other recordings of me that are made during the course of volunteering with the Komen Affiliate.

This Release shall be construed under the laws of the state in which the Komen Affiliate is located.  In the event any provision of this Release is deemed unenforceable by law, (i) the Komen Affiliate shall have the right to modify such provision to the extent necessary to be deemed enforceable; and (ii) all other provisions of this Release shall remain in full force and effect.  

I understand that I have given up substantial rights by signing this Release, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent allowed by law.

[NOTE: The following language shall only apply in the event the Komen Affiliate is located in California: This Release extends to claims and facts unknown and unsuspected to exist at the time of executing this Release.  All rights under Section 1542 of the California Civil Code are hereby expressly waived with respect to any of the claims, injuries, or damages described in this Release.  Section 1542 of the California Civil Code reads as follows:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.
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