Form Center

2. 
4. PERSONAL INFORMATION
6. Last Name
7. First Name
8. Middle Inital
10. Address1
12. City
13. State
14. Zip
16. Email address
18. Home Phone
19. Work Phone
20. Cell Phone
22. Date of Birth
23. Place of Birth
25. EMERGENCY CONTACT
27. First Name
28. Last Name
30. Relationship
31. Phone
33. AVAILABILITY TO VOLUNTEER
35. Days of Week*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday

    1. Friday
    2. Saturday
    3. Sunday
36. Hours
38. EDUCATION
40. High School or GED Diploma earned?
42. College
44. Other
46. LANGUAGE SKILLS (including sign language)
48. PREVIOUS/CURRENT VOLUNTEER EXPERIENCES
50. Organizations/Responsibilities
52. How did you hear about our RUOK program?
54. EMPLOYMENT
56. Employer
58. Position/Duties
60. Address1
62. City
63. State
64. Zip
66. REFERENCES
68. Reference 1 Name
69. Contact Phone
70. Email
72. Relationship
73. How long known?
75. Reference 2 Name
76. Contact Phone
77. Email
79. Relationship
80. How long known?
82. Comments
84. Castle Rock Senior Center Partnership

    The Castle Rock Police Department's RUOK? program partners with the Castle Rock Senior Center. We ask that all RUOK? volunteers read, acknowledge and agree to the terms of the Castle Rock Senior Center's Confidentiality Agreement and Conflict of Interest Policy in order to participate. Please see below.

86. Confidentiality Agreement

    1. I have read and agree to the terms of the Confidentiality Agreement
87. Confidentiality Agreement

    Acknowledgment of Confidentiality Concerning the Business of the Castle Rock Senior Activity Center:

    I, the undersigned Staff, Board Member, Committee Member and/or Volunteer of the Castle Rock Senior Center, acknowledge I have been informed and am aware of the confidential nature of the information I may overhear or be a part of while conducting the business of the Castle Rock Senior Center. I am advised and aware that:

       - Reports and records concerning staff, members, volunteers, guests and/or visitors or transportation riders of the Center or the programs or events of the Center are confidential and are not public information. Any information received during our regular business shall be considered confidential and only shared with Staff, Board Members and or our Legal Advisor when necessary.

       - Nothing in this Agreement shall prevent me from commenting publicly about general trends or concerns perceived with the business of the Castle Rock Senior Center. The Castle Rock Senior Center will not indemnify me, defend me, or contribute financially to my defense should civil or criminal claims be made against me if I choose to speak publicly concerning my service of the Castle Rock Senior Center.

       - I understand that as the undersigned, I conduct myself as a representative of the Castle Rock Senior Center, and that as such a representative I understand and agree I will conduct myself professionally with regard to the sensitive nature of some of our dealings with each other and the community.

89. Conflict of Interest Policy

    1. I have read and agree to the terms of the Conflict of Interest Policy
90. Conflict of Interest Policy

    Volunteers may not use privileged information gained as a result of their volunteer status for personal gain or benefit or to benefit relatives, friends or acquaintances.

    If a volunteer or volunteer’s family has an interest (including, but not limited to, serving as partner, manager, stockholder or employee) in any business that sells products and or services to the Castle Rock Senior Center (Center) or if a volunteer has information on the Center that may be used for personal gain, the volunteer shall advise the Executive Director or Board President of such interest in writing.

    The notified official shall determine if a conflict of interest exists and shall then notify the Volunteer. If such a conflict is found to exist, the volunteer will be given the option of terminating their volunteer status. Failure to comply with these provisions may result in immediate dismissal.

92. APPLICANT RELEASE STATEMENT

    I am presently an applicant for a volunteer position with the Castle Rock Police Department. In order to be considered for such a position, the Police Department needs to obtain verification of past performance. I hereby authorize you to transmit to the Castle Rock Police Department any and all information concerning my past employment performance including, but not limited to, the information required in this form. I do hereby release and so discharge the Police Department or its agents or employees, together with the employer whose name and address appears on this form, or any of its agents or employees, from any liability, claim, or demand of any nature whatsoever, arising out of the dissemination of the information requested herein.

94. By entering my name below, I understand that I am providing an electronic signature which will serve as authorization and verification of the accuracy and completeness of the information I have provided*

    Enter Full Name: First, MI, Last. Signature is required for form submittal.

96. Affirmation:*

    1. By submitting this form, I certify that all statements made on this application are true and complete. (Required)
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit

* indicates a required field