Volunteer Application — SAFE Alliance

1

Personal Information

Date of Application * Required

Date of Birth * Required

Legal Name * Required

Preferred Name / What You Go By

Gender Identity

Pronouns

Race

Ethnicity

Home Address * Required

City * Required

State

ZIP * Required

Email * Please enter a valid email

Best Contact Phone * Required

This phone is a

Cell Home Work

Employer

Length of Employment

Educational Background

2

About Your Interest in SAFE

How did you learn about SAFE?

Why have you chosen SAFE? (Check all that apply)

Academic course credit Personal growth Personal familiarity with domestic violence, sexual assault, or abuse & neglect Commitment to ending violence in the community Other (describe below)

Which issue areas interest you? (Check all that apply)

Domestic Violence Sexual Violence Child Abuse

What do you hope to gain from your volunteer experience? * Required

Which personal strengths will you draw on when working with adults or children in crisis?

Which volunteer opportunities interest you? (Refer to the Volunteer Position Descriptions)

Any special concerns about working with survivors of child abuse, domestic, or sexual violence?

3

Experience & Background

Do you have prior experience with children and youth?

Yes No

If yes — ages and types of activities

What training would be most helpful to prepare you for volunteering with SAFE?

Previous volunteer experience (organization, position, length of time)

What did you like most and least about prior volunteer experiences?

Special interests, hobbies, civic or church groups, activities you enjoy

Current club / organization memberships (include offices held)

Languages other than English (and level of competency)

Describe your volunteer availability

Have you ever received services from SAFE (or its founding agencies Austin Children's Shelter or SafePlace)?

Yes No

4

Emergency Contact

Emergency Contact Name * Required

Relationship * Required

Phone Number * Required

Address

Alternative formats of training materials and reasonable accessibility accommodations are available upon request. Please contact Volunteer Services if you need accommodations.

References

Please supply 3 letters of reference. Each reference must be submitted by the individual writing the letter and emailed directly to safevolunteer@safeaustin.org with the subject line: "[Your Name] Reference Letter".
At least one reference must be a professional reference (employer, professor, or prior volunteer supervisor).

5

Confidentiality Agreement

This Confidentiality Agreement covers the services provided by The SAFE Alliance ("SAFE") and the information shared by clients, as well as information designated by SAFE as sensitive information, including confidential business or personnel matters. The confidentiality agreement also includes photography and video, which may not be taken or shared unless it is done as part of the services provided and a SAFE Alliance-approved consent form has been signed.

Any information concerning the identity of individuals served by SAFE is to be kept confidential at all times, except as otherwise specified below.

SAFE may be required to share confidential information when:

SAFE is bound by law to report suspected child abuse, elder abuse and/or the abuse of a person with a disability; homicide, homicidal or suicidal threats. Staff is authorized to comply with the law by making all required reports.

A SAFE client signs a specific authorization to release information and the authorization is in the client's file.

SAFE may need to comply with court orders and properly issued subpoenas.

SAFE staff are bound by state law requirements to report abusive, illegal or sexually exploitive acts by other mental health professionals or organizations.

SAFE has video cameras installed on its campuses and in SAFE-owned vehicles for the safety and security of clients, staff, and visitors. SAFE does not share video recordings except as required by law or if SAFE suspects illegal activity. To protect privacy and confidentiality, SAFE does not allow audio/video recording or photos of other clients or staff on personal devices.

If necessary for a client's benefit, client information may be shared among SAFE staff or volunteers to assist in service provision. If there is a public health emergency and SAFE has knowledge that you may have been exposed to a communicable disease, SAFE may be required by law to report your name and contact information to public health authorities.

I have read, understood, and agree it is my legal responsibility to comply with this Confidentiality Agreement while at SAFE and after ending my association with SAFE.

I am a

Signature (type your full legal name) * Required

Date * Required

Parent / Guardian Signature (if applicant is a minor)

Printed Name

6

Liability Release

I understand that while working at SAFE I may come into contact with infections and contagious diseases such as hepatitis B, salmonella, ringworm, tuberculosis, pink-eye, AIDS, and other types of diseases. I understand that SAFE may not be aware that some of the residents have a disease, and that, even if the staff is aware, they may not tell other persons due to privacy concerns. I also understand that SAFE is not undertaking any duty to determine whether a resident has a disease.

I also understand that it is my personal choice as to the precautions I wish to take. While I understand that SAFE is in no way undertaking the responsibility for advising me as to appropriate precautions to take, I am aware that health officials recommend wearing disposable gloves (which are supplied at the shelter) while cleaning up spills of blood, bloody saliva, urine, feces, or vomit, and using a mouthpiece for mouth-to-mouth resuscitation.

I have made the choice to be here and I will not hold SAFE liable for health problems I may incur while at any SAFE facility even if they are caused in whole, or in part, as a result of the negligence of a staff member or resident.

Do you have a physical condition that would affect your ability to lift up to 40 lbs?

Yes No

If yes, please explain

Volunteer Signature (type full legal name) * Required

Date * Required

7

Mutual Commitment Form & Physical Intervention Policy

SAFE agrees to:

Provide quality training to volunteers
Provide support and assistance to volunteers
Furnish supplies and facilities to enable volunteers to function effectively
Provide an agency policy regarding volunteer responsibilities and expectations

As a volunteer for SAFE, I agree to:

Make a commitment of at least 8 hours per month for a minimum of 6 months beginning after all training is completed (some programs require a larger time commitment).
Affirm that information provided in this application is true and correct to the best of my knowledge.
Inform SAFE if I am named in complaints or indictments or convicted of offenses.
Be open to on-going suggestions for improvement from staff.
Participate in any and all training required by programs.
Adhere to the confidentiality policy.
Adhere to emergency, security, and shift procedures specified for the program site.
Maintain appropriate boundaries with clients.
Never allow family, friends, or anyone else on SAFE premises without prior approval of my volunteer supervisor or other authorized SAFE staff.
Never carry a firearm or other type of weapon on any SAFE premises.
Attend required volunteer support meetings or continuing education classes.
Notify my Volunteer Supervisor if I will be unavailable to volunteer for a given period of time.
Understand that if I miss more than 2 shifts and fail to notify staff, my volunteer status may be terminated.
Accept the Volunteer Director's final decision as to my involvement with SAFE.
Take any questions regarding SAFE policies, staff decisions, or the performance or conduct of another volunteer to my supervisor.
Understand that SAFE reserves the right to terminate volunteer assignments at any time.

I realize that breaching this agreement may be cause for my immediate dismissal.

Volunteer Signature (type full legal name) * Required

Date * Required

Volunteer Physical Intervention Policy

I understand that as a volunteer with SAFE:

I will let staff handle aggressive situations.
If I am volunteering at the SAFE Children's Shelter campus, I will go to another cottage or locate staff to request help when needed.
I will move away from any aggressive situation.
If a resident is being aggressive, I will engage the other youth who are not involved and encourage them to move away from the crisis situation.
I will not place my hands on a resident to contain, restrain, or otherwise prohibit the movement of a resident.
I will not contain, restrain, or otherwise prohibit the movement of a resident for any reason, nor may I assist staff in doing so.

I understand that as a volunteer I may not ever put hands on a resident during a conflict situation. I cannot physically intervene with any children/youth receiving services by SAFE. I will let trained staff manage any crisis situations and will not physically engage for any reason, even if asked to do so by staff. If I physically intervene during a crisis with any resident, I acknowledge that I could lose my placement as a volunteer. I will contact Volunteer Services Staff if I witness a crisis or otherwise significant incident or am asked to do something I was trained not to do.

Volunteer Signature (type full legal name) * Required

Date * Required

8

Consent & Release for Use of Likeness

I hereby grant permission to The SAFE Alliance—including any and all of its subsidiaries, licensees, successors, assignees, and any and all other individuals, agencies, corporations, organizations, etc. acting on behalf of The SAFE Alliance, including but not limited to Austin Children's Shelter and SafePlace—to obtain and use the voice, image, photograph, likeness, and/or video of myself by any medium (including but not limited to video, audio, and photo or other image, natural or altered in any state by any manner). Permission extends into perpetuity.

For a valuable consideration, receipt of which is hereby acknowledged, I hereby grant the Released Party all ownership rights and the absolute and irrevocable right and permission to copyright, use and publish the Likeness of myself. The Likeness may be copyrighted, used and/or published individually or in conjunction with other photography or video works, and in any medium (including without limitation, print publications, public broadcast, social media, and other digital formats) and for any lawful purpose, including without limitation, trade, exhibition, illustration, promotion, publicity, advertising and electronic publication.

I grant the above consent and release for use of my likeness. *

Your Full Legal Name * Required

Date * Required

Almost done! By clicking Submit, you confirm that all information provided is accurate to the best of your knowledge. An electronic copy of your application will be sent to the SAFE Volunteer Services team for review. You will be contacted about next steps.

SAFE Volunteer Application

Application Submitted!