Volunteer

Volunteer Information

Availability

Emergency Contact Information

Background

Have you ever been convicted of a crime, been assessed deferred adjudication for a crime, pled guilty or nolo contendere to a crime, or been convicted of any misdemeanor to include DWI or conviction for use, possession, sale of drugs or chemical substances?

Have you ever been convicted of a crime for assault, burglary, theft, or misappropriation of fiduciary property or property of financial institution, or securing document by deception that is punishable as a class A misdemeanor?

Application Disclosure

As a volunteer with Umphress Terrace, I understand the services I provide are without pay and I am not authorized to do anything directly to or for a resident that requires the knowledge and/or license of a medical professional.

I hereby agree to abide by all rules, policies, and guidelines of the Volunteer program either verbal or written while volunteering with CC Young.

I hereby agree to release, indemnify, defend and hold harmless the volunteer program, Umphress Terrace, all of their officers, directors, employees from any and all claims or causes of action of any kind.

I hereby agree that if, while preforming any volunteer services, I may gain confidential knowledge as it pertains to a resident and/or Umphress Terrace business information, I will not disclose or produce any confidential resident and/or business information outside the volunteer services which I am providing for Umphress Terrace. I acknowledge and understand unauthorized access, use, disclosure or reproduction of any resident information is a direct violation of this Agreement and may result in my immediate removal form Umphress Terrace's facilities and the volunteer program. I agree I will take appropriate steps to protect any confidential resident information.

I certify that the information on this application is complete and correct to the best of my knowledge.

Typing the name listed below shall have the same force and effect as my signature and by typing such name below and submitting this application form I agree to all terms and conditions stated herein.

Agreement

To submit our application, you must (a) indicate your agreement to all terms and conditions contained on this application and (b) certify the accuracy of all information you provide in this application. Submit your application and indicate your agreement and indicate your certification by checking the "I Agree" button below.