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Diocese of Grand Island
Child Protection Office
2708 Old Fair Road, Grand Island, Nebraska 68802
Initial Volunteer Application
*
Indicates required field
In which Parish / School / Diocesan Office will you be volunteering?
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Name
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First
Last
Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Preferred Phone Number
*
Email
*
Occupation
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Employer
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Employer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Previous Employment, please include addresses (last 7 years)
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Previous Volunteer Experience
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Current Memberships (religious, community, business, labor, or professional organizations)
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Experience working with children/youth in other organizations
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References
Please list those who are familiar with your character as it relates to working with youth,
including at least one
current or past employer or volunteer supervisor
. References will be checked.
Reference #1
*
Reference #1 Address
*
Line 1
Line 2
City
State
Zip Code
Country
Reference #1 Phone Number
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Reference #2
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Reference #2 Address
*
Line 1
Line 2
City
State
Zip Code
Country
Reference #2 Phone Number
*
Reference #3
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Reference #3 Address
*
Line 1
Line 2
City
State
Zip Code
Country
Reference #3 Phone Number
*
Background Questionnaire
1. Has your driver's license ever been revoked or suspended?
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Yes
No
2. Have you ever been convicted of a criminal offense?
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Yes
No
3. Have you ever been charged with child abuse or neglect?
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Yes
No
4. Has any civil or criminal complaint, or any other written complaint, ever been made against you relating to sexual abuse, sexual harassment, or exploitation?
*
Yes
No
5. Have you ever terminated your employment or had your employment terminated for reasons related to allegations of civil or criminal complaints of sexual abuse, sexual harassment, or exploitation against you?
*
Yes
No
6. Have you ever been directed to receive any medical or psychological treatment, including counseling, involving your sexual abuse, sexual harassment, or sexual exploitation of other persons?
*
Yes
No
7. Did you enter into an agreement with any past employer not to divulge the true reason for termination of employment?
*
Yes
No
8. Has your employment or volunteer service eligibility ever been denied by a diocese or other entity?
*
Yes
No
9. Do you use illegal drugs?
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Yes
No
10. Other than above, is there any other fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people?
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Yes
No
If Yes to any of the above, explain.
*
I understand that the information I have provided may be verified if necessary, by contacting persons or organizations named in this application or by contacting any person or organization that may have information concerning me. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the local parish, the Diocese of Grand Island, and the officers, employees, and volunteers thereof. In signing this application, I affirm that the information I have given is true and correct.
Acknowledgement of Receipt
I hereby acknowledge that I have received a copy of the
Child Protection Policy
and/or
Volunteer Policy Summary
,
Code of Conduct
,
and
Summary of Rights under the Fair Credit Reporting Act
of the Diocese of Grand Island, Nebraska; and that I have read them and understand their meaning. I agree to conduct myself in accordance to the Policy and Code of Conduct. I have personally read and completed the background questionnaire.
Signature (Electronic entry of my name serves as my written signature)
*
Date
*
Please note: Once you click Submit, you have to complete Step 2. The instructions are on the next page.
Submit