Volunteer Application - PCC - Volunteer in Portage

Volunteer Type

Youth

Adult

Personal Information

First Name

Middle Initial

Last Name

Preferred Name

Preferred Gender Identity

Address

City

State

Zip

Drivers License Number

Date of Birth

Age

Contact Information

Primary Phone

Secondary Phone

Preferred Method of Contact

Phone

In Case of Emergency Contact(s)

Please note, all adults need at least one contact, youth MUST have two.

Emergency Contact 1 Name

Emergency Contact 1 Relationshp

Emergency Contact 1 Primary Phone

Emergency Contact 1 Secondary Phone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Primary Phone

Emergency Contact 2 Secondary Phone

In order to complete our mandatory background check, we need the following information:

Race

Previous or other name(s) known by (maiden or legal name changes):

Please briefly list and explain any misdemeanors or felony charges or convictions (if any):

Please note that convictions and/or charges will not necessarily disqualify an applicant and any information regarding charges or convictions will remain confidential

Professional and/or Personal References

Reference 1 Name

Reference 1 Relationship

Reference 1 Primary Phone

Reference 1 Secondary Phone

Reference 2 Name

Reference 2 Relationship

Reference 2 Primary Phone

Reference 2 Secondary Phone

Hour Requirements (if any)

I am completing these hours because (choose best fit)

Court Mandated

School Requirement

OtherOther

Court or other referring agency

Contact person at referring agency

Referring Agency Phone

Total number of hours needed

Deadline for completion of hours

Total number of hours desired to complete at PCC

I am available:

Monday Start Time

Monday End Time

Tuesday Start Time

Tuesday End Time

Wednesday Start Time

Wednesday End Time

Thursday Start Time

Thursday End Time

Friday Start Time

Friday End Time

Please note that in typical situations, the max weekly commitment for adults is 8 hours; for youth 4 hours.

I hereby give authorization to PCC and its professional staff to verify the information provided with any organization or individual listed. I also authorize the release of information about my volunteer relationship with PCC to referring agencies as necessary. I certify that all information I have provided is true. I understand that falsifying any information is grounds for termination of my volunteer relationship with the Portage Community Center. My signature authorizes this information as well as gives Portage Community Center permission to conduct a criminal background check through the Michigan State Police ICHAT System.

Signature of Volunteer

Date

To be completed by the parent or guardian of a volunteer under the age of 18:
I have reviewed the information provided by my child and certify it to be true. I understand that my child must agree to follow all policies and procedures listed while performing his or her duties as a PCC volunteer. I understand that if my child is to violate any terms of the above listed, PCC will terminate the volunteer agreement. I give the staff of PCC permission to run a criminal background check on my child through the Michigan State Police ICHAT System and to confirm all provided information with referring agency as necessary.

Signature of Youth Volunteer's Parent or Guardian

Date

Transportation Agreement of Minor

To be completed by the parent or guardian of a volunteer under the age of 18.

In order to ensure the safety of youth volunteers PCC requires a detailed approval of transportation limits or requirements for your child. Please note if you wish to put NO transportation restrictions on your child, please check “any” on the list below to release PCC of responsibility of ensuring only approved transportation.

Any changes to the approved methods of transportation will need to occur at minimum verbally directly to staff (not left in a voicemail or given to another volunteer) in emergency situations only or in writing prior to the date of needed change.

I certify that my child is able to get home in the following ways (check all that apply):

Ride only with approved individuals listed below, emergency contacts, parent(s) or guardian(s)

Ride by any individual over the age of 18

By his or her own transportation (own vehicle)

Ride with any friends or siblings under the age of 18

Public Transportation

Walking/Biking

Any

Please indicate how you would like to be informed of transportation issues

Please list all individuals that are approved to take your child home

Please note that emergency contacts listed in the application and parents and guardians are automatically qualified to transport a child, individuals to list in this section may include siblings, aunts, uncles, grandparents, family friend, etc.

Name

Relationship

Primary Phone

Secondary Phone

Name

Relationship

Primary Phone

Secondary Phone

Name

Relationship

Primary Phone

Secondary Phone

Please list all individuals that are NOT approved to take your child home

Name

Relationship

Name

Relationship

Name

Relationship

Signature of Youth Volunteer's Parent or Guardian

Date

Code of Conduct for PCC Youth

The goal of the PCC’s Youth Program is to provide youth the opportunity to become engaged in positive activities that help develop social and interpersonal skills, increase their sense of responsibility within the community and foster self-esteem. The staff and volunteers of PCC will make every effort to assist individual youth in achieving his or her goals.

To protect each youth’s right to a safe and orderly environment, policies governing youth conduct have been developed. The following is a list of unacceptable youth behaviors and the consequences that will result for any youth, regardless of age, who is participating in a PCC program who participates in any of these listed behaviors. This list is offered as an example of misbehaviors and is not intended to be all-inclusive.

The following behaviors may result in dismissal from a PCC program as well as a referral to Police.

Arson
Possession of a weapon
Transferring and/or sale of alcohol and/or illegal substances

The following behaviors will result in consequences, which may include but are not limited to, temporary suspension from a PCC program, referral to Police, and/or restitution meeting with parents:

Use or possession of alcohol, tobacco and/or illegal substances
Assault or fighting
Theft
Profanity of any kind, written, spoken, graphics, and/or actions of vulgarity
Vandalism
Insubordination, persistent disobedience and/or disorderly conduct
Intimidation or Harassment
Ethnic intimidation or harassment
Unauthorized leaving of the premises or group activity off premises
Improper bus behavior

Staff has the final decision on what behavior is acceptable or inappropriate.

Repeated inappropriate offenses will NOT be tolerated and is grounds for dismissal.

No student will be dismissed from a PCC program until the parent/guardian has been reached and transportation arranged.

My signature means I have read, understand, and agree to follow the terms of the above Code of Conduct.

Signature of Youth

Date

Signature of Youth's Parent or Guardian

Date

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