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WSSB Volunteer Application

STATE OF WASHINGTON WASHINGTON STATE SCHOOL FOR THE BLIND

2214 E. 13th St. · Vancouver, Washington 98661-4120 · (360) 696-6321 · FAX # (360) 737-2120

Dear Volunteer Applicant: Thank you for offering your time to make a difference in the lives of children who are blind or visually impaired. Volunteers in our schools demonstrate that there are adults in the community that care about children and value education. To be a volunteer at the Washington State School for the Blind (WSSB) you must complete the Volunteer Clearance Application Process prior to being assigned to a volunteer position. The information disclosed on these forms will be used only in making the initial decision of whether you are eligible to volunteer and will not be used or disseminated for any other purpose. This process includes the following documentation: 1. VOLUNTEER APPLICATION 2. REQUEST FOR CRIMINAL HISTORY INFORMATION TO WASHINGTON and/or OREGON STATE PATROL - We request this information to obtain Washington and/or Oregon State Patrol (WSP/OSP) records of any criminal convictions for felony crimes, as well as any offenses against persons, civil adjudications of child abuse, and the disciplinary board final decisions from the WSP/OSP criminal identification system. WSSB Superintendent approval may be required if the WSP/OSP report shows evidence of a criminal history background. 3. APPLICANT DISCLOSURE FORM - This form is required by law in order to be in compliance with RCW 43.43.830, RCW 43.43.832 and RCW 9.96A.020. 4. VOLUNTEER EXPECTATION AGREEMENT - This form is for your safety as well as for the protection of the children you work with. By signing this form you verify that you understand the expectations and appropriate behaviors while working as a volunteer with WSSB students and staff. 5. COPY OF PHOTO IDENTIFICATION - Government/State issued driver's license or ID card. Please provide a clear, readable copy. If you have any questions regarding the clearance process, please feel free to contact the WSSB Volunteer Coordinator at (360) 947-3290.

Volunteer Application

Contact Information

Name *

Address *

Country

City

State

Zip code

Home Phone Number

Cell Phone Number

Email *

How long have you lived in this community/state?

If less than 2 years at current address, please give previous address

Employment Information

If not employed, list last employer

Are you currently employed?

Yes

Place of Employment

Job Title

Job Address

Job Phone Number

Can we call you at work?

Yes

Supervisor's Name

Can we call your supervisor?

Yes

References

Please list three people who know you well, at least one professional reference. Please do not list relatives.

Reference #1 Name

Reference #1 Phone

Reference #1 Relationship

Reference #2 Name

Reference #2 Phone

Reference #2 Relationship

Reference #3 Name

Reference #3 Phone

Reference #3 Relationship

Why do you want to Volunteer at WSSB?

Who recommended you or how did you hear about us?

Previous Volunteer Experience

Summarize your special skills and qualifications you have acquired from previous volunteer work, or through other activities, including hobbies or sports.

Person to Notify in Case of Emergency

Emergency Contact Name

Emergency Contact Address

Emergency Contact Phone Number(s)

Emergency Contact E-Mail Address

Agreement and Signature

I agree to abide by the policies of the Washington State School for the Blind. The information that I have provided on this form is true and complete to the best of my knowledge. I understand that WA State
School for the Blind may verify my information and untruthful or misleading answers will result in rejection of this application and removal of my name from the volunteer register. I will not represent myself as an employee and do not expect to receive any monetary compensation for my services. I also understand that I may be subject to further screening and observation by the volunteer coordinator to ensure that I have been placed in an appropriate assignment. Should my volunteer placement prove to be inappropriate WSSB reserves the right to change or discontinue my volunteer service.

Name

Volunteer Application Signature

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Alternate Signature Line - Volunteer Application

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Washington State School for the Blind Volunteer Disclosure Form

Washington State Law requires applicants for prospective employment and volunteer positions to complete this form.

Answer Yes Or No to each listed item.

Have you ever been convicted of any crimes against children or other persons as defined in Section 1 of Chapter 486, Laws of 1987, and listed as follows: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second or third degree rape; first, second, or third degree statutory rape; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communications with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second or third degree child molestation; first or second degree sexual misconduct with a minor; first or second degree rape of a child; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling prostitution; or any of these crimes as they may be renamed in the future?

Yes

Have you ever been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor?

Yes

Have you ever been found by a court in a domestic relations proceeding under the Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?

Yes

Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person?

Yes

Ever been found in any disciplinary board final decision to have abused or financially exploited any person 60 years of age or older who has a functional, mental or physical inability to care for himself or herself or who is a patient in a state hospital?

Yes

Ever been found by a court in a protection proceeding (Chapter 74.34) to have abused or financially exploited a person 60 or older who has a functional, mental, or physical inability to care for himself or herself or who is a patient in a state hospital?

Yes

Have you, within the last ten (10) years been convicted of any felony other than the crimes described above?

Yes

If your answer is “YES” to any of the questions above, please describe and provide the date(s) of the findings of the penalty imposed.

Authorization

The Washington State School for the Blind is authorized to request the Washington State Patrol to make available a prospective employee’s or volunteer’s record for convictions of offenses against children or other persons, adjudications of child abuse in a civil action, disciplinary board final decisions, and any subsequent criminal charges associated with the conduct that is the subject of the disciplinary board’s final decision. Any misrepresentation of willful omission of facts shall be sufficient cause for disqualification of this application.

Disclosure Signature

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

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Alternate Signature Line - Disclosure

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Washington State School for the Blind Request for Criminal History Information

Child/Adult Abuse Information Via Washington/Oregon State Patrol RCW 43.43.830 through 83.43.845

Please complete, sign and date this form to be considered for a volunteer position(s) at the Washington State School for the Blind (WSSB). Washington residents must present a valid Washington Driver license or State ID card. Oregon residents must present a valid Oregon Driver license or state ID. I understand that the services I will be providing are voluntary in nature and I do not expect to receive any compensation or benefits from WSSB.

Applicant Information

(To be completed by applicant)

Date of Birth

Sex

Race

Current Name

(Last, First, Middle)

Birth Name

(Last, First, Middle)

Other last names you have been known by or write none if none

Nicknames and other first names you have been known by or write none if none

If you have you been convicted, or have charges pending for any crime, give the crime, state where it occurred and the conviction date or charge status.

Crime

State

Conviction Date

If charge is pending, what is the status?

Second Crime

State of Second

Conviction Date of Second

If charge of second is pending, what is the status?

List current driver's license or state identification number

State ID was issued

ID Upload

Please attach a copy of your driver's license ID in PDF or JPG format.

I have authorized this request by my signature - Criminal History

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Alternate Signature Line - Criminal History

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Washington State School for the Blind

Volunteer Expectation Agreement

Thank you for your interest in volunteering for the Washington State School for the Blind (WSSB). This information is provided as a guide while volunteering. Please review the following carefully and ask any questions that may arise. We want the time you spend volunteering to be a positive experience for all. Relationships: For the protection of all, the relationship between you and any student you become acquainted with through volunteering at WSSB must be kept appropriate at all times. Continuing your volunteer relationship through out-of-school contact, such as phone calls, home visits, or visitations to your home, social events, office, vehicle, or activities is not permitted without specific directive from a teacher and/or prior written parental permission. This prohibition, of course, would not restrict out-of-school contact with students who are family friends or known to you through community contacts. Appropriate Touching: Handshakes, “high five”, are the only safe and friendly ways to touch a child when you are volunteering. For some children, or for some cultures, even these gestures may be unwelcome. No child should be subject to unwelcome touching no matter how well intended. If a child ever inappropriately touches you, please inform a staff member right away. Communication: WSSB provides equal opportunity in programs and employment and does not discriminate on the basis of race, color, national origin/language, creed/religion, sex, sexual orientation - including gender identity, disability, or the use of a service animal by a person with a disability, age, marital status, honorably discharged veteran or military status, HIV/Hepatitis C status. The school provides equal access to the Boy Scouts and other designated youth groups. Contact Human Resources at (360) 947-3311 regarding questions and complaints of alleged discrimination; or a letter may be submitted to Human Resources, 2214 E. 13th Street, Vancouver WA 98661. Confidentiality: As a volunteer you must respect and maintain confidentiality in regard to personal information obtained regarding a child or his/her family with certain exceptions. Reasonable suspicion of abuse, neglect, sexual harassment, illegal or dangerous activities should be shared with staff. Be assured they will follow up on the information. Discipline: Any discipline of a student should be left up to a staff member. Physical punishment is never permitted. School Safety Plan: In the event of an emergency while you are on site (fire, earthquake, etc.) you need to be familiar with the safety plan of the location you volunteer in. First Aid: Occasionally emergencies happen while you are working with students. Volunteers are not expected to perform any type of first aid. If a medical emergency occurs please contact the school office. Please be aware of universal blood and body fluid precautions. I have read and understand the above expectations.

Volunteer's Name

Signature - Expectations

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Phone Number