Diocese of Laredo New Volunteer Checklist Volunteer Information Form * Testimonial of Suitability for Volunteer Service/Ministry (To be completed only by individuals without a Social Security number) Ethic Acknowledgement Statement Volunteer Background Check Form Safe Environment Training Certificate of Completion (Obtained from online training http://safeandsacred-laredo. org ) All the above forms should be sent to the Human Resources Office Todos estos formularios deben enviarse a la Oficina de Recursos Humanos Submit all forms to: Presentar todas las formal: Attn: Human Resources Office 1901 Corpus Christi St. Laredo, Texas 78043 PHONE: (956) 727-2140 FAX: (956) 727-9904 Nom: All entities should maintain a file on all volunteers. These fauns should be secured in the Administrator's office. NOTA Todas las entidades deben mantener un archly() de todos los voluntarios. Estos formularios deben ser asegurados en la oficina del Administrador. "Only submit if applicable DIOCESE OF LARED 0 Volunteer Information Form/Formulario de Information de Voluntariado (Please Print of Type/tetra de molde por favor) (Use Legal Name/use nombre legal) Name: Nombre SS # Last/Apellido FirsVprimer nombre M/I Also Known As: D.O.B Tambien conocido como Fecha de nacirniento Address: Apt# Direction City: State: Zip Code: Ciudad Estado Codigo Postal Home Phone: ( Work/Cell Phone: f ) Trabajo / Celular Telefono de la casa Name: of Parish, School or Entity: Ministry: Nombre de Parroquia, Escuela o Entidad Volunteer Position: Start Date: How Long? Position Voluntaria Fecha de Inicio Cuanto Tiempo Full Time/Tiempo Completo Part Time/Tiempo Parcial Number of hours per week Numero de horas por semana Work hours: to Horas de trabajo How long have you known this person? REFERENCE NAME Address (City, State, Zip) Nombre de Referencia Direccion (Ciudad, Estado, Codigo Postal) Daytime Phone Claim tiempo hace que conoce a esta persona? Telefono durante e1dia Work/Volunteer Related-/-Trabajo/Voluntarios relacionadas Work/Volunteer Related-/-TrabajoNoluntarios =beton adoa =song (Non -Family Member)-/-Pectonal (no roiunbto d. 1. Lanai.) ersonal (Nan-Faauly Member}/-Persond (no oniernaro de la Emilia Family Member-/ -Miembro de la familia EMERGENCY CONTACT INFORMATION: 1NFORMACION DE CONTACTO DE EMERGENCIA: Name: Relationship: Nombre Relation Apt# Address: Direccion City: State: Ciudad Estado Business/Cell Phone :( Telefono Trabajo/Celular ) Zip Code Codigo Postal Home Phone ( ) Telefono de Casa Volunteer Signature Date Firma de Voluntario Fecha May/2009 Has this person agreed to provide a reference? Esta persona ha accedido proporcionar una referencia? Diocese of Laredo Employee/Volunteer Code of Ethics Employee/Volunteer Name Date Nombre de Empleado/Voluntario Fecha Church personnel will exhibit the highest Christian ethical standards and personal integrity. Church personnel will conduct themselves in a manner that is consistent with the discipline and teachings of the Catholic Church. Church personnel shall provide a professional work environment that is free from physical, psychological, written, or verbal intimidation or harassment. Church personnel will avoid taking unfair advantage of a counseling relationship for their personal benefit. Church personnel will not physically, sexually or emotionally abuse or neglect a minor or adult. Church personnel will share concerns about suspicious or inappropriate behavior with their pastor, their principal, the Diocesan Chancellor, Vicar General or BishOp. Church personnel will report any suspected abuse or neglect of a minor to the Texas Department • of Family and Protective Services. Church personnel will accept their personal-reSPonSibilitYt° prolebt minors and adults from all forms of abuse. *** ** **'** * ** * ** * *** * ** ****** *** * * ******zk ** *** ******** i;*** ** ****** ** *;sc****-*-*** *** * ******** El personal de la Iglesia expondra los estandares etvos cristianos mas altos y la integridad personal. El personal de iglesia se comportaraen una manera cOnseCtenth con la disciplina y las enseflanzas de la Iglesia CatoliCa- : El personal de iglesia propordionaralin ambiente de trabajo profeSiOnal que es libre de intimidaciOn e a o acoso fisica, psicologica, escrita;. Verbal . . . El personal de iglesia evitard tciniar la ventaia_injusta de una relacioti orientacion para su ventaja personal El personal de iglesia no abusaiaLESicaniente; : kalmente o emocionalmente o descuidard a un menor o a un adulto El personal de iglesia compartirkpteOcUpaciOnes poi . el comportamiento sospechoso o inadecuado con su pastor, su principal, el Canciller Diocesan, • General de Vicario u Obispo El personal de iglesia relatard cualquier abuso sOipeCliado:o abandono de un menor al Departamento de Texas de Familia y Servicios ProteCt6i4(TexaSIDePartraent of Family and Protective Services.) rSonal para proteger a menores de edad y El personal de la Iglesia aceptara su responsap'. adultos contra todas las forums de abuso. que es v rb l I have reviewed the Code of Ethics of the Diocese of Laredo and agree to abide by its requirements. He revisado el codigo de etica de la Diacesis de Laredo y estoy de acuerdo en cumplir con sus requisitos. Printed Name/imprimir Nombre Title/rituio Parish/D ep artrnent/S chool/Other City/Ciudad Parroquia / Departamento / Escuela / Otros S i gnatur e /F irm a May/2009 Date/Fecha DIOCESE OF LAREDO Employee/Volunteer Authorization and Release for the Procurement of a Report Requestor: Date (Name of Parish, School or Entity) I, the undersigned consumer, do hereby authorize DIOCESE OF LAREDO AND CATHOLIC MUTUAL GROUP, INC. by and througl independent contractor, LexisNexis, to procure a report on me. The above mentioned report may include employment and education verification; personal references; citations; a social secu number verification; present and former addresses and criminal history/record. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any report prepared on me up written request to LexisNexis that is made within a reasonable time after the date hereof and further understand that additional crimir background checks may be performed periodically during my tenure of employment in the DIOCESE OF LAREDO. I further authorize any person, business entity or governmental agency that may have information relevant to the above to disclose tt same to DIOCESE OF LAREDO AND CATHOLIC MUTUAL GROUP, INC. by and through LexisNexis, including but not limited to, ar courthouse, any public agency, any and all law enforcement agencies regardless of whether such person, business entity c governmental agency compiled the information itself or received it from other sources. I hereby release DIOCESE OF LAREDO AND CATHOLIC MUTUAL GROUP, INC., LexisNexis and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, of whatever kind, tc me, my heirs, or others making such claim or demand on my behalf, for procuring, selling, providing, brokering, and/or assisting with the compilation or preparation of the consumer report and/or investigative consumer report hereby authorized. CRIMINAL HISTORY: THIS INFORMATION WILL BE VERIFIED Complete Address History for the past 7 years (address; City & State, Zip): No No No No Have you ever been convicted of a felony? Have you ever entered a plea of guilty to a felony? Have you ever entered a plea of "No Contest" to a felony? Have you ever been placed on deferred adjudication? Yes Yes Yes Yes If you answered yes to any of these questions, please explain: Volunteer Employee SS # Name: DL # Last PEddle First / City Address: Daytime Telephone Number: Date of Birth State Issued: ( / St Gender: Zip ) Date: Signature: FOR OFFthE USE ONLY This Individual Identified above has Comments: Human Resource Staff . Not Clear Cleared Date: Please Note: Submit check payable to "Diocese of Laredo"'for the fee of S5 for each form submitted. May/2009 M F