Interfaith Ministries for Greater Houston

Volunteer Information Intake

Thank you for your interest in volunteering with Interfaith Ministries for Greater Houston (IM). All information on this form will be strictly confidential and will only be used in the management of Volunteers at IM. For more information contact Tiffany Harris or call 713.533.4922.

Interfaith Ministries for Greater Houston
VOLUNTEER INFORMATION INTAKE FORM

Underlined fields are required.

Title:
First Name:
Middle Name:
Last Name:
Address1:
Address2:
City:
State:
Zip Code:
Home Phone:
Cell:
E-mail:
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone:
Social Security Number

Please provide the information below so that we may complete a criminal background check.
Birthdate (mm-dd-yy) and gender:	Female Male
Ethnicity:	(for reports to our donor agencies)
Do you have a valid driver's license?	Yes No
License #:	State: Exp. Date:
Do you have current Auto Liability Insurance?	Yes No Exp. Date:
Name of Insurance Company:
Have you lived in another city or state in the last three years?	Yes No
If yes, where?
Have you ever been convicted of a crime?	Yes No
If yes, please explain:
Please be prepared to show your driver's license and proof of insurance, upon request, at any time while volunteering.

Place of Employment:
Number of Years:
Type of Business:
Job Title:
Work Phone:
E-mail:
Fax:
Does your employer have a matching gifts program?	Yes No
Does your employer have a Time-Off policy for Volunteer Services?	Yes No

Education
Highest Level:
Degree or trade obtained:
Are you currently attending?	Yes No
Name of Institution:
Area of Study:
Religious Affiliation:
Congregation/Faith Community Name:
Are you a member of a professional, civic, or other organization?	Yes No
If yes, please describe:
Please list any special interests, hobbies, etc.:
Do you speak, read or write a foreign language? If yes, please list the languages:	Yes No
Are you volunteering to fulfill a class requirement or community service hours? If yes, how many hours do you need to complete?	Yes No

Availability
Please check the day(s) you are available to volunteer.	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours available to volunteer:

Program Interest.	Congregational Disaster Preparedness Faith Tours Food for Seniors Foster Grandparents Interfaith Relations Meals on Wheels AniMeals on Wheels Refugee Services Gala Committee Women's Gathering Steering Committee
How did you learn of volunteer opportunities at Interfaith Ministries? Please check all that apply. We are always interested in the most effective ways to recruit new volunteers.
IM Volunteer Mosaic Newsletter/Mailing/Etc. Volunteer Career Fair IM Client Newspaper Volunteer Matching Website School Congregation IM Employee Radio/Television United Way Fair Friend/Relative
Website (Please specify):
Other (Please specify):
REFERENCES
Please list three non-relative individuals we can contact as a reference. Please include name, address, telephone number, nature of relationship and how long they have known you.

I understand that the information on this application will be verified. I authorize a release of information concerning my character, employment history, criminal history and suitability to work with children, seniors or refugees. I hereby release from all liability and damages both Interfaith Ministries for Greater Houston (IM) and those individuals or companies who provide such information. I hereby waive all claims for damage or loss to my person or property which may be caused by any act, or failure to act of IM, it's officers, agents or employees or any of IM service locations, it's officers, agents or employees. I assume the risk of all dangerous conditions in or about property where I am doing volunteer service and waive any and all specific notice of the existence of such condition.

I hereby agree to the use of my likeness as rendered in any photography/video. I give this permission to IM, its licensees and its member organizations. I understand that I will not receive compensation of any kind and that my likeness may be reproduced by any means currently existing or developed in the future.

I Agree I Disagree

(If you disagree and still submit your application, an IM staff member will call you.)

Volunteer or Parent/Guardian Name:
Date:

CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK
AUTHORIZATION/WAIVER/INDEMNITY

I hereby give my permission in exchange for good and valuable consideration for Interfaith Ministries for Greater Houston to obtain information relating to my criminal history record through Volunteer Houston. The Criminal History Record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargain and deferred adjudication. I understand that this information will be used, in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I remain a volunteer here, the Criminal History Check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification if I dispute the record as received. I, the undersigned do, for myself, my heirs, executor and administrators, hereby remise, release and forever discharge and agree to indemnify and defend Volunteer Houston and Interfaith Ministries for Greater Houston and each of their officers, directors, employees, and agents from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney's fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer. This indemnification does not include any negligence on the part of the volunteer center.

Volunteer or Parent/Guardian Name:
Date:

CONFIDENTIALITY AGREEMENT
Individuals have the right to the protection of their personal information about them in their relationship with Interfaith Ministries for Greater Houston (IM) during and following the process of obtaining services. To address this issue, IM requires the Undersigned, as staff or volunteer, to sign this confidentiality agreement. The Undersigned agrees to abide by the following:

1. The Undersigned agrees that during his or her involvement with IM, and thereafter as long as necessary to assure confidentiality, any private, privileged or confidential information he or she receives including but not limited to financial data (excluding tax and audited annual financial reports); personal information regarding staff, board members and volunteers, client information; and personal observations of client shall be considered and kept as the private, privileged and confidential records of IM.

2. Information shall not be divulged to any person, firm, corporation or other entity except on the direct authorization of the CEO or designee.

3. If the Undersigned is provided with computer access by an assigned password, the computer information accessed by the Undersigned is confidential and may not be shared with others. The assigned password must also be kept confidential and shall not be divulged or given to others for their own use other than as required by IM procedures. In the event that the Undersigned believes another person had access to his or her password, the Undersigned shall immediately request a new password.

4. Upon the termination of his or her relationship with IM, the Undersigned agrees that he or she will continue to treat the information as private, privileged, and confidential and will not release any such information to any person, firm, corporation, or other entity, by written or verbal statements except upon direct written authority of the CEO. Failure to maintain the information as private and privileged will be considered a breach of confidentiality. IM shall be entitled to an injunction by any competent court to enjoin and restrain the unauthorized disclosure of such information.

5. The Undersigned agrees to abide by IM's internal confidentiality procedures and protections regarding the access, dissemination, input and collection of confidential and private information with regard to data collection, IM records, the IM computer system, E-mail, the Internet, facsimiles and other methods of transferring or recording information.

6. All information relating in any manner to IM participants or organization, whether prepared by the Undersigned or otherwise coming into the Undersigned's possession, shall be the exclusive property of IM and shall be returned immediately to IM upon termination of the Undersigned's relationship with IM or upon IM's request at any time.

7. If all or any portion of any of the provisions of this Agreement shall be declared invalid, illegal or unenforceable by laws applicable hereto, then the performance of the offending provision or provisions shall be excused by the parties and such invalidity, illegality, or unenforceability shall not affect any other provision of this Agreement.

By signing this form, I acknowledge that I understand and agree with the expectations outlined in this agreement.

Volunteer or Parent/Guardian Name:
Date:

VOLUNTEER HANDBOOK
Download the IM Volunteer Handbook

I have read and I understand all items described in the IM Volunteer Handbook. I agree to abide by all volunteer requirements.
I Agree I Disagree

Please send me Mosaic, IM's quarterly publication.

3217 Montrose Blvd, Houston, TX 77006, 713.533.4900