the complete Volunteer Application here

INDIVIDUAL VOLUNTEER APPLICATION
NAME:_______________________________________________ DATE: ____________________
MAILING ADDRESS: _____________________________________________________________
CITY: _________________________________
STATE: __________ ZIP: ________________
HOME PHONE: _______________________ E-MAIL ADDRESS: _________________________
CELL PHONE: _______________________________ WORK PHONE: _____________________
EMPLOYER: _____________________________ OCCUPATION: _________________________
DATE OF BIRTH: ______________________
EMERGENCY CONTACT NAME, RELATIONSHIP & PHONE NUMBER: ________________
________________________________________________________________________________
Are there any medical problems or issues of which we should be aware in the event of an
emergency? If so, please explain.
________________________________________________________________________________
_______________________________________________________________
_
Do you have any special interest or hobbies?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________
______________
Are you familiar with the Ronald McDonald House? ____ yes ____ no. If yes, how did you come
to know of us? ___________________________________________________________________
_______________________________________________________________________________
Why are you interested in becoming a volunteer at the Ronald McDonald House?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
What do you hope to gain from your volunteer experience? ________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________
______________
What talents, experience, skills, knowledge, etc. do you feel you can bring to the Ronald McDonald
House? _________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please list any previous volunteer experience: (list organizations, length of service, responsibilities
and supervisors)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
When are you available to volunteer? Please list day and times.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please indicate your area of interest:
_____ Receptionist
Help support the RMHC staff by answering phones, screening visitors, accepting donation deliveries, assisting
families and any other tasks as needed. Shifts are available on weekdays and weekends in 4 hour increments.
_____ House Warmer
Helping to keep the House clean, sanitized and germ-free for our families is a priority. House Warmers work
primarily in the kitchen, but also assist in cleaning and upkeep of other areas of the House. House Warmers
will be trained in proper food handling and storage guidelines. Shifts are available on weekdays and weekends
in 4 hour increments)
_____ Family Room Host
Family Room volunteers help us maintain the Ronald McDonald Family Room located on the 3 rd floor of
Wolfson Children’s Hospital. Volunteers have the opportunity to interact with and support families during a
very difficult time. Family Room volunteers must complete both the RMHC Jacksonville application and
orientation process and the Wolfson Children’s Hospital application and orientation process. Family Room
volunteers must have their flu shot and TB test, both are provided by Wolfson Children’s Hospital. (Must be
18 or older and have graduated from high school).
Special Programs
Whether your hobby is art, music, scrapbooking, martial arts or yoga, you can share it with the families of
RMHC Jacksonville. Professional skills such as haircuts, massages and manicures are also a great way to help
our families. Flexible schedule based on House activities.
Van Driver
Help transport families to and from the hospital, grocery store and other local destinations in the RMHC
Jacksonville van. Volunteer van drivers must meet insurance requirements.
List two local references (not relatives) that you have known for at least one year:
Name _____________________________________
Occupation _________________________________
Daytime Phone ______________________________
Length of Acquaintance _______________________
Name ______________________________________
Occupation __________________________________
Daytime Phone _______________________________
Length of Acquaintance ________________________
I hereby apply for active membership as a Ronald McDonald House Volunteer. I agree to abide by
all rules and regulations governing this organization. I agree to attend an interview and training
before being assigned to service.
____________________________________________
Applicant’s Signature
________________________
Date
BACKGROUND INVESTIGATION
To be considered for a volunteer position at the Ronald McDonald House Charities of Jacksonville, Inc.
applicants are subject to a background investigation with the Florida Department of Law Enforcement and
other state, out-of-state, and local agencies.
Applicants are evaluated on the merits of their qualifications for positions available regardless of the
individual’s race, sex, color, national origin, age, disability, religion, marital status, or status as a veteran.
This Background Investigation is being completed for criminal background histories by state and/or federal
agencies. Persons who have been convicted of any felony offenses or misdemeanor offenses involving
drugs, child abuse, assault, or any violent behaviors are not eligible to volunteer at the Ronald McDonald
House Charities of Jacksonville, Inc.
1. Have you ever been convicted of, or pled guilty, no contest or nolo contendere to a crime? This includes
DUI or DWI, a criminal conviction, debarment, sanction or exclusion related to Medicare, Medicaid, or any
other federal or state – funded health care program (s), or ineligibility for participation in a federally or statefunded health care program?
____Yes____ No If yes, give details (date, place, offense (s), disposition etc. )
2. Have you ever been charged with a crime and either been placed on a court ordered probation, had
adjudication with held, entered a pre-trial intervention program, or have any criminal charges now pending?
____Yes _____No If yes, give details.
3. List all cities,states & zip codes where you have resided outside of Florida within the past seven
(7) years.
_____________________________________________________________________________
_____________________________________________________________________________
4. PLEASE PRINT ALL INFORMATION AND SIGN AT THE BOTTOM
First and middle names should be as appears on your birth certificate.
In the other name(s) field please include all last names that you have ever had.
LAST NAME:_______________________________________________________________________
FIRST NAME:_______________________________________________________________________
MIDDLE NAME:____________________________________________________________________
OTHER NAME(S) BY WHICH YOU ARE KNOWN, OR HAVE BEEN KNOWN, INCLUDING
MAIDEN NAME: ____________________________________________________________________
____________________________________________________________________________________
SOCIAL SECURITY # : ______________________________ DATE OF BIRTH : _________________
DRIVER’S LICENSE #: __________________________________ STATE OF ISSUANCE: ________
CHECK APPROPRIATE SPACES:
SEX:
Male_____
Female_____
RACE: Caucasian_____African-American_____Asian_____Hispanic_____Other___________________
_____________________________
Signature of Applicant
__________________________
Date
Ronald McDonald House Charities of Jacksonville, Inc.
CONFIDENTIALITY CERTIFICATE
I, _____________________________ (please print) understand that any information regarding our
families and donors at the Ronald McDonald House or the Family Room is confidential. I
understand that this information is confidential under the Florida Statutes as well as other State and
Federal regulations.
_________________________________________
Volunteer Signature
______________________
Date
SOLICITATION AND / OR DISTRIBUTION OF LITERATURE
I understand that I may not solicit and / or distribute literature to families or staff of the Ronald
McDonald House on RMH property. This includes selling, vending, making or collecting
contributions of money or signatures, or engaging in verbal persuasion, or delivering merchandise
during hours.
________________________________________
Volunteer Signature
______________________
Date
PHOTO POLICY
I understand that for the safety and protection of everyone, all volunteers and visitors to the Ronald
McDonald House are not permitted to take photos of resident families.
________________________________________
Volunteer Signature
______________________
Date
Confidentiality & Non-disparagement Agreement
(“Volunteer”) and
This Agreement is made between
Ronald McDonald House Charities of Jacksonville,
(“the Company”) on this
day of
,20
.
Volunteer will perform services for Ronald McDonald House Charities of Jacksonville, Inc., which may
require the Company to disclose confidential and proprietary information (“confidential information”) to the
Volunteer. Confidential information is defined as any information of any kind, nature, or description
concerning any matters affecting or relating to the Volunteer’s services for the Company the business or
operations of the Company and/or the products, plans, processes, or other data of the Company.
Accordingly, to protect the Company confidential information that will be disclosed to the Volunteer, the
Volunteer agrees as follows:
1. Volunteer will refrain from accessing confidential information except when needed to perform the job
function.
2. Volunteer will hold the confidential information received from the Company and its customers in strict
confidence and shall exercise a substantial degree of care to prevent disclosure to others.
3. Volunteer will not disclose or divulge either directly or indirectly the confidential information to others
unless first authorized to do so in writing by the Company.
4. Volunteer will not reproduce the confidential information nor use this information commercially or for any
purpose other than the performance of her/her duties for the Company.
5. Volunteer will, upon the request or upon termination of his/her relationship with the Company deliver to
the Company any notes, documents, equipment, and materials received from the Company and its
customers or originating from its activities for the Company.
6. The Company shall have the sole right to determine the treatment of any information that is part or
project specific received from Volunteer, including the right to keep the same as a trade secret, to use
and disclose the same without prior notice, to file copyright registrations in its own name, or to follow any
other procedure as the Company may deem appropriate.
7. The Company reserves the right to take disciplinary action, up to and including termination, for violations
of this agreement.
8. The Company reserves the right to obtain a court order, if necessary, to prevent the Volunteer from
violating this agreement.
9. The Volunteer represents and warrants that it is not under any preexisting obligations inconsistent with
the provisions of this agreement.
10. Furthermore, the Volunteer and the Company shall refrain from expressing (or causing others to
express) to any third party any derogatory or negative opinions or statements concerning the other party,
including the Company’s executives, directors, members, managers, or clients, or concerning the
Company operations.
11. The Volunteer and the Company recognize and acknowledge that irreparable harm to either Volunteer or
the Company would result from either party breaching the confidentiality and non-disparagement
conditions and requirements in this Agreement, and that monetary damages alone would not provide
adequate relief for any such breach.
Signing below signifies that the Volunteer agrees to the terms and conditions of this
agreement stated above.
Volunteer Signature
Date
Human Resources
Date
Ronald McDonald House Charities
Grant, Assignment, Release and Waiver
I hereby grant to Ronald McDonald House Charities, Inc. (RMHC), its local Chapters and programs,
advertising and promotional agencies, and their agents (collectively, “RMHC”), the irrevocable, unrestricted
right to use, publish, display and distribute materials bearing my name, voice, likeness or any other
identifiable representation of myself. These materials may appear in any form, style, color or medium
whatsoever now or hereafter known (including, without limitation, photographs, videotapes, films, sound
recordings, software, drawings, prints, broadcast, internet and electronic media).
I agree that all materials containing any identifiable representation of me (including, without limitation, all
negatives, plates and masters of any photographs, files, prints or tapes) shall be and remain the sole and
exclusive property of RMHC, and I hereby assign any proprietary right I may have acquired in or to such
material to RMHC. I hereby release and forever discharge RMHC from any and all liability and damages
relating to the use of my name, voice, likeness or any other identifiable representation of me.
I hereby waive any right I may have to inspect or approve the finished materials or any part or element
thereof that incorporates my name, voice, likeness or any other identifiable representation of myself.
I have agreed to the above in consideration of the opportunity given to me by RMHC to appear in these
materials. I acknowledge that I have fully read and understand this document and that I have had any
questions regarding its effect or the meaning of its terms answered to my satisfaction. I certify that I am at
least 18 years of age, unless this document is also signed by my parent or legal guardian.
Volunteer Name (please print)
Signature
Address
Date Signed
City, State, Country, Zip/Postal Code
I represent that I am a parent or legal guardian of the person identified above, who is a minor. I consent to
the use of his/her name, voice, likeness and/or other identifiable representation of him/her as set forth above.
Signature of Parent or Guardian of volunteer
Minor’s Date of Birth
Name of Parent or Guardian (please print)
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From time to time, RMHC materials are shared for McDonald’s promotional purposes to demonstrate
their support of RMHC. Please check this box if you prefer that we NOT share your information/images.