Thank you for volunteering. We need YOU! Please fill out the various parts of this form according to your interests. Parts marked with (*) are mandatory for all volunteers. Do not hesitate to call for help at (877)-343-2856 Monday-Friday 8:30am-5:00pm Pacific Time. CLICK ON THE FIRST GREEN BAR TO GET STARTED...



PART 1: ALL VOLUNTEERS (*)

Information About You








[optional, please reduce to less than 1 megabyte]
Availability, Training
    
Volunteer Availability







I have previous experience in:



























Education: Pick the highest degree earned





References

Your First Reference





Your Second Reference





Your Third Reference

PART 2: ALL VOLUNTEERS: YOUR VOLUNTEER INTERESTS (*)

Interests

Please check any of the boxes below that you may be interested in volunteering for. You will be contacted and receive further information based on your selection to help you find the right fit. We rely on you, our volunteers, and want and honor your value to our organization and unique way you may choose to give.

If you place your mouse on top of any of the checkboxes which look interesting, a description of the
volunteer position will pop-up. Read it carefully; more information will follow once you have submitted the form.

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

PART 3: ALL VOLUNTEERS: CONFIDENTIALITY STATEMENT (*)

I have read and agree to the following:

AFFEC Volunteer
Statement of Understanding
and Confidentiality

Confidentiality and Privacy Policies

I understand that, as an AFFEC volunteer, I am subject to the same rules and laws of confidentiality that apply to paid staff. I agree to keep confidential any and all information concerning all persons served by AFFEC, including children birth parents, and prospective adopting parents, and including all DHS clients. I will not divulge to any outside person or agency any confidential information about any such person, unless I am specifically authorized to do so by AFFEC. “Confidential information” includes, among other things:

  1. the name, address, photo, or other identifying information about such persons;
  2. the fact that such person is working with AFFEC;
  3. any information contained in such person’s file; and
  4. any financial, medical, marital, or health information about such person.

I understand that I must keep this information confidential at all times and even after my period of volunteer service ends. I further agree to act in a responsible and professional manner when providing services to clients in an AFFEC program, and agree to adhere to the policies governing ethics and conduct of AFFEC and the State of Oregon. All records dealing with specific clients must be treated as confidential. Although the agency is liable for your acts within the scope of your duty, giving information to an unauthorized person could be interpreted as not acting within the scope of duty and the agency could refuse to support you in the event of legal action. Violation of Oregon Revised Statute regarding confidentiality of records is punishable upon conviction of a fine of not more than $1000 or by imprisonment in the county jail for not more than 60 days, or both.

Reporting Requirements

I understand that I am required to keep track of my hours of service. A time sheet will be submitted to the AFFEC/Program Director each month.

Conflict of Interest

If at any time I become aware of a conflict of interest, including knowledge of any persons I may know who are involved in a case that may be assigned to me, I will notify the Director of AFFEC/Program Director immediately.

As an AFFEC volunteer, I shall not take any action that would result in personal financial benefit. I will not ask for or receive for myself or for any member of my household, directly or indirectly, any monies or gifts from clients.I agree to not use any information gathered or shown for my own personal benefit. I understand that all information is privileged and confidential and agree to treat it as such; not using anything for personal gain. I understand that I will be given access to AFFEC’s database that carries case related information as well as child listings and again agree to not use for personal gain, i.e., my own child searches. Evidence of such will be grounds for immediate dismissal.

Further, I understand that volunteer, work experience, intern and practicum service does not in any way assure me of any future position as an employee of AFFEC or DHS, nor does it entitle me to any benefits of regular employment, such as salary, medical or dental insurance or any other incident of regular employment.

Personal Professionalism

I agree to attend orientation and training sessions and meetings as required. High ethical standards are essential to the maintenance of public trust and confidence in our program. Volunteers shall therefore maintain a professional standard of conduct and shall not engage in conduct that would bring discredit upon the AFFEC or DHS.

Mandatory Abuse Reporting

As Agents of the State, volunteers must, by law, report any suspected child and elder abuse. Anyone making such reports in good faith shall have immunity from any liability, civil or criminal. I understand that the A Family for Every Child may terminate or modify the terms of this work agreement at any time. My signature below certifies that I have read and understand all information presented in the agreement points presented in this document. I understand that my duty as an agent of AFFEC and DHS is to abide by the laws of Oregon and policies of both agencies, including preservation of confidential information, including PHI (Protected Health Information).

Please type in your name to indicate that you agree.

PART 4: ALL VOLUNTEERS: AUTHORIZATION FOR RELEASE OF INFORMATION (*)

Interests

AUTHORIZATION FOR RELEASE OF INFORMATION /
PRIVACY ACT NOTICE

 

A FAMILY FOR EVERY CHILD

880 Beltline Road – Springfield, OR 97477

(541) 343-2856 / (541) 343-2866 FAX

www.afamilyforeverychild.org

 

PLEASE READ THE DISCLOSURE BELOW:  CHECK THE BOX TO INDICATE AGREEMENT.

In checking this consent form below, you are authorizing A Family For Every Child to request information from the sources you are providing for verification purposes.  A Family For Every Child will not sell nor solicit your private information to outside sources.  This authorization is valid for five years from the date of this form's submission.

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I hereby authorize all former employers, persons, educational institutions, law enforcement agencies and military services to release information related to my work record or in reference to information provided and release them from any liability or responsibility from doing so. I understand that omitting or giving false pre-employment information is reason for disqualification or dismissal and that an offer of voluntary placement is subject to verification of employment history satisfactory to A Family For Every Child. www.afamilyforeverychild.org.  I understand that this request is due in part because of the business partnership contract between A Family For Every Child and the State of Oregon – Department of Human Services, primarily Child Welfare.

    

PART 5: FOR Photography VOLUNTEERS

Statement of Agreement

Heart Gallery Family Logo

 

Heart Gallery Photographer’s Statement of Agreement

 

I, as a photographer for A Family For Every Child / Heart Gallery hereby state that:

 

  1. I understand that I am providing a charitable service to A Family for Every Child - Heart Gallery for the purpose of photographing children who are in need of adoptive families.
  2. I agree to be in compliance with all federal and state regulations concerning children, including but not limited to laws concerning abuse and neglect, confidentiality, and child pornography.
  3. I certify, under penalty of perjury, that I am not a convicted felon, nor under suspicion of committing a felony.  I further certify, under penalty of perjury, that I have never committed a crime, and am not under suspicion of committing a crime, involving a child.
  4. I understand that I cannot use these photographs or any representation of the photographs for any other purpose, including but not limited to advertising, on line portfolios, web sites or displays.  I may not use these photographs in any way without signed consent from the individual states Department of Human Services. However you are welcome to use our logo and link our site, so your visitors know of your services provided, we are happy to provide our logo, and would welcome yours on our site.
  5. I agree to keep confidential any information that I might learn of these children, including such information as current residence, date of birth, last name, school, or any other identifying information.  I further agree to be in compliance with all federal and state regulations concerning the confidentiality of this information.
  6. I understand that A Family for Every Child - Heart Gallery and/or any representative or contractor of the Department of Human Services may use the photographs I have taken, without further permission from me and for any use deemed appropriate by the aforementioned entities.  I further understand, however, that those entities will not sell the photographs except in a context that promotes A Family for Every Child - Heart Gallery, such as a commemorative book.
  7. I understand that I cannot hold A Family for Every Child - Heart Gallery and/or any representative or contractor or the Department of Human Services liable for any accident or injury to me or to my property that might occur while photographing the children.
  8. I agree to take the photographs that, to the best of my ability, highlight the children themselves, fully understanding that the purpose of these photographs is to enable “heart connections” to be made with prospective adoptive families.  I agree that if a choice must be made between highlighting my artistic skills, and highlighting a child’s personality, I will choose to highlight the child’s personality.
  9. I understand that given the nature of the endeavor, I am given no guarantee that my photograph(s) will be displayed or used for recruitment.  I understand that there are reasons beyond my control for which a photograph might not be displayed, to include adoption before release of photographs, or a change in the child’s status.
  10. I understand that I am bound by all the provisions set out in this agreement and failure to comply with any provision will subject me to any damages or remedies that may be available to the Department of Human services or the A Family for Every Child - Heart Gallery.
  11. I understand that this agreement shall be forever binding.

Agreed to this 18th day of May, in the year 2012.

 

X (spell out your signature to indicate you agree)

    

 

    
    
I am willing to travel:




PART 6: FOR Family Finding VOLUNTEERS

Interests

Step(s) Interested In



PART 7: FOR Mentoring VOLUNTEERS

Interests








if you participate in sports, which ones




















Outdoor activities you want to try?



















Indoor activities you want to try?
















What are your favorite restaurants?














How do you express yourself?














What types of movies do you like?



















































Skills willing to teach older kids?














PART 8: YOUR QUESTIONS AND COMMENTS

Please write any questions or comments into the box below.
DO NOT FORGET TO WHEN YOU ARE DONE!