APPLICATION FOR TEEN VOLUNTEER PROGRAM

Name: Date

Address: City: State: ZipCode:

Phone: Home: E-mail:

Are you between the ages of 14-17 years old?

School: Year:

Do you need to schedule your volunteer hours around a work schedule? :

How did you hear about the volunteer opportunities at Harbor House?

Do you speak Spanish? Do you speak Hmong?

Please mark what days and times that you are available to volunteer:

Monday 6:00 - 8:00 Children's Group (For Resident's Children Only)

Tuesday 6:00 - 7:30 Chidlren's Group

Wednesday 6:00 - 8:00 Children's Group

Thursday 6:00 - 7:30 Children's Group

Weekends (Flexible Hours)

Why do you want to volunteer for Harbor House Domestic Abuse Program? (You may check more than one.)

Help others

Because my school requires it. How many hours required:

I want something to do outside of school and family activities

I want to learn more about domestic abuse

I have been encouraged to do so by others. Who:

Think of a time when you sought or received help from someone.

Describe your feeling about this. Your comments may be either positive or negative::

REFERENCES:

Please list three. Name/address/phone number/relationship

Name:	Phone:
Address:	Relationship:
Name:	Phone:
Address:	Relationship:
Name:	Phone:
Address:	Relationship:

CONFIDENTIALITY POLICY:

The primary purpose of the Harbor House Domestic Abuse Programs is to provide protection and safety to victims and the children of victims. The use or disclosure of any information by anyone affiliated with Harbor House (staff, volunteers, board members) that concerns the victims or the children of victims who receive services from Harbor House for any purpose is prohibited by state law. It is, therefore, a policy of the Harbor House Domestic Abuse Programs that any agent of Harbor House (staff, volunteers, board members) will treat all contacts and information regarding victims and children of victims who receive services from Harbor House as confidential.

No information Regarding service recipients will be divulged either directly or indirectly to anyone.

This includes:

Harbor House Domestic Abuse Programs may not contact the perpetrator nor may they require that the victim contact the perpetrator.
Harbor House may not reveal the victims or the victim's children's whereabouts, or require the victim to reveal such whereabouts.
Files and all written documents regarding victims and the children of victims are to be maintained in a confidential manner.
Victims will be informed of their rights to confidentiality during the intake process.
Staff, volunteers and board members are still bound by this condition of confidentiality upon completion of employment, volunteer commitment or board term once this form is signed.

CONFIDENTIALITY PLEDGE AND AGREEMENTS:

By clicking the submit button:

I name: hereby affirm that I have read the above policy and do fully realize the importance of maintaining confidentiality. I understand that there is a state law prohibiting disclosure (section i, 895.67.) I agree to abide by this policy.
I hereby authorize Harbor House Domestic Abuse Programs to contact the above references to determine if I can become a volunteer.
I give permission to Harbor House Domestic Abuse Programs to perform a criminal background check in order to determine if I can become a volunteer.
The information that I submitted on this application is true and correct to the best of my knowledge.