Fillable Form Dc5-601a - 2015 Volunteer Application Form (Page 2 of 2) in pdf

N CONSIDERATION OF THE OPPORTUNITY TO SERVE IN THE

EPARTMENT OF

ORRECTIONS AS A

ITIZEN

OLUNTEER



I acknowledge that today I have been furnished with a copy of the volunteer rules,

 I have read, understood and signed an Acknowledgement of Responsibility to Maintain

Confidentiality of Medical Information, DC2-813 and the PREA training “Read and Sign” for

volunteers.



I understand that I am responsible for reading and complying with the rules.



I will work in cooperation with staff.



I will honor the civil and legal rights of all offenders/inmates.



I will not use my official position to secure privileges or advantages for myself.



I will report unethical behavior or rule violations to an appropriate Department supervisor.



I will not discriminate against any offender/inmate, employee, or prospective employee on

the basis of race, gender, creed, national origin, or religious preference.



I acknowledge the drug-free workplace policy of the Department of Corrections and I know I

am subject to random drug testing.



I agree to abide by the policies and procedures regarding confidentiality of records and

medical information.

WAIVER OF LIABILITY

I hereby waive all liability to the Department of Corrections and its employees, for any and all

injuries which may occur to me during my term of service with the Department of Corrections.

Volunteers and interns, when working for the department, are covered by Worker’s Compensation in

accordance with Chapter 440 of the Florida Statutes. I understand that I am the person responsible to

ensure that I am in compliance with any and all applicable State Law, Department of Corrections

Policy, or any Regulation which may affect me during this period.

I confirm that all the information on the application is correct and have read the Acknowledgement of

Responsibilities, Waiver of Liability, and agree to abide by the conditions therein.

Signature:

Date:

For Those Completing Regular Volunteer Training:

Person Conducting Volunteer Training:

Location:

Official Use:

F.A.S.T. Pin #:

FCIC/NCIC

Training Date:

Date:

Hits:

Yes

Approved:

Date:

(Approving Authority

)

Signature of Volunteer

Date:

Volunteer’s Printed Name:

An annual background check should be done for each active regular service volunteer. The temporary volunteer badge is produced in accordance with “Identification Cards,”

Procedure 602.056.

The Chaplaincy Services Administrator or institutional lead Chaplain is the approving authority when the volunteer has no previous period of incarceration or supervision.

When a proposed volunteer has a previous period of incarceration or supervision, the approving authority is the Assistant Secretary for institutions or designee. (“Volunteers,”

Procedure 503.004).

D C 5 - 6 0 1 A ( R e v i s e d 1 0/ 2 2 / 1 5 )

I n a c c o r d a nc e w i t h s . 1 1 9. 0 7 1 ( 5 ) ( a ) 2 , y o u r s o c i a l s e c u r ity number is being collected i n o r de r t o c o m p l e t e a n

FCIC/NCIC security re port so that y o u can be approved as a v ol u nt e e r. T he D e p a r t m e n t w i l l n o t u s e t he soc i a l

s e c u r i t y n u m b e r c ol l e c t e d f o r a ny p u r p os e o t h e r t ha n t h e p u r pose pr ovided above. Qualifie d a p p l ic a n t s a re c o n si de r e d

w i t h o u t di s c ri m i n a t i o n b a se d u p o n r a c e , c o l o r, na t i o na l o ri g i n, age religious preference, or ha ndic ap. Intentional ly

f a l s i fy i n g o r o mi t t i n g in f or ma t i o n may r e s u l t i n d i sap p r o v a l o f y ou r v o l u n te e r a p p l ic a ti o n