THANK YOU for your interest in becoming a volunteer with our organization! Volunteers are critical to helping us achieve our goal of helping our Club members succeed in school and in life. We look forward to learning more about you and strive to make the experience meaningful and rewarding for both you and the youth we serve. The process of becoming a Boys & Girls Club of St. Lucie County Volunteer is as follows: Complete a Volunteer Registration Form Complete the VECHS Waiver Agreement & Statement and Acknowledgment and Authorization forms. Turn in all completed forms to the Administrative Office (3104 Avenue J, Ft. Pierce, FL). Fingerprints. Instructions for scheduling fingerprints will be given to the potential volunteer after initial background check is conducted. The Boys & Girls Clubs of St. Lucie County will pay the fee for the fingerprints. Upon review of the criminal history results you will be notified of your eligibility to volunteer. Once approved for volunteering you will be referred to the Club as per your request on the Volunteer Registration Form. The Club/Program will then train you on the Volunteer Policies and Procedures and will work with you to develop a plan for your volunteer experience. Again, THANK YOU for your interest in providing your time and talents to help us fulfill our mission to enable all young people, especially those who need us most, to reach their full potential as productive, caring, responsible citizens. Special Note Youth volunteers who are 18 years of age or younger do not complete this process. They become registered Club members, have their membership fee waived and will be tracked using normal Club procedures for tracking member volunteer hours. These youth will not be required to complete a background screen.
VOLUNTEER REGISTRATION FORM Please PRINT all information clearly. Last Name: First Name: Middle Name: Current Address: Past Address: Home Phone #: ( ) Street City State Zip Code Street City State Zip Code Cell Phone # ( ) Employer: Work Phone #: ( ) Previous/Current Volunteer Experience: Email Address: Education Level: High School Graduate School College Other Special Skills/Hobbies/Interests: How did you hear about Volunteer Opportunities at the Club? Personal Reference Name: Home Phone #: Cell Phone #: Years Known: Personal Reference Name: Home Phone #: Cell Phone #: Years Known: Have you ever been convicted of, or plead guilty, had adjudication withheld, pled nolo contendere or nolle prosequi to a crime? Yes No Are you currently awaiting trial, sentencing or other disposition of a criminal charge? Yes No If the answer to either question is yes, please explain (state the date, type of crime, place of occurrence, disposition): *Conviction of a crime will not necessarily disqualify you for a volunteer opportunity. Each conviction will be judged on its own merit with respect to time and volunteer relatedness.
Please check where you would like to volunteer Chuck Hill Unit 198 NW Marion Avenue Port St. Lucie, FL 34983 772.249.4173 Garden Terrace Unit 3104 Avenue J Fort Pierce, Florida 34947 772.464.6634 Infinity Unit 1011 23 rd Street Fort Pierce, FL 34950 772.464.6634 Ken Pruitt Unit 10673 SE Lennard Road Port St. Lucie, FL 34983 772.398.0028 Administrative Office 3104 Avenue J Fort Pierce, Florida 34947 772.460.9918 School Based Clubs Office 2000 SE Village Green Drive Port St. Lucie, Florida 34952 772.398.0291 School Based Clubs Bayshore Floresta Lakewood Park Manatee Mariposa Morningside Oak Hammock Palm Pointe River s Edge St. Lucie West Westgate Windmill Point VOLUNTEER AVAILABILITY: Please check the days that you are available and indicate times (for example: Monday from 10AM to 1PM). Monday Tuesday Wednesday Thursday Friday Weekend Events Choose the age group(s) in which you are interested: 6 to 9 10 to 12 13 & older No Preference Please list any specific volunteer areas of interest under the following categories: Education Arts Sports Recreation Office/Clerical Tell us about yourself: What experience do you have in related areas? I CERTIFY THAT ALL STATEMENTS ON THIS APPLICATION ARE TRUE AND HEREBY AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I FURTHER UNDERSTAND THAT VOLUNTEERING WILL BE CONDITIONAL UPON INITIAL AND CONTINUAL SATISFACTORY BACKGROUND SCREEN RESULTS. Signature of Applicant: Date:
Florida Department of Law Enforcement Criminal Justice Information Services Division/User Services Bureau VECHS WAIVER AGREEMENT AND STATEMENT Volunteer & Employee Criminal History System (VECHS) for Criminal History Record Checks under the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes Pursuant to the National Child Protection Act of 1993, as amended, and section 943.0542, Florida Statutes, this form must be completed and signed by every current or prospective employee, volunteer, and contractor/vendor, for whom criminal history records are requested by a qualified entity under these laws. I hereby authorize Boys & Girls Clubs of St. Lucie County (Qualified Entity) to submit a set of my fingerprints and this form to the Florida Department of Law Enforcement for the purpose of accessing and reviewing Florida and national criminal history records that may pertain to me. I understand that I would be able to receive any national criminal history record that may pertain to me directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34, and that I could then freely disclose any such information to whomever I chose. By signing this Waiver Agreement, it is my intent to authorize the dissemination of any national criminal history record that may pertain to me to the Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. I understand that, until the criminal history background check is completed, you may choose to deny me unsupervised access to children, the elderly, or individuals with disabilities. I further understand that, upon request, you will provide me a copy of the criminal history background report, if any, you receive on me and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I may obtain a prompt determination as to the validity of my challenge before you make a final decision about my status as an employee, volunteer, contractor, or subcontractor. A national criminal history background check on me has previously been requested by: (Name and Address of Previous Qualified Entity) (Year of Request) I have OR have not been convicted of a crime. If convicted, describe the crime(s) and the particulars of the conviction(s) in the space below: I do OR do not authorize you to release my criminal history records, if any, to other qualified entities. I am a current or prospective (check one): Employee Volunteer Contractor/Vendor Signature: Date: Printed Name: Address: Date of Birth: TO BE COMPLETED BY QUALIFIED ENTITY: Entity Name: Boys & Girls Clubs of St. Lucie County Address: 3104 Avenue J, Fort Pierce, FL 34947 Telephone: 772.460.9918 Fax: 888.337.9918 FDLE Assigned Qualified Entity Number: E56040019 & V56040019 ORIGINAL - MUST BE RETAINED BY QUALIFIED ENTITY
DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION The Boys & Girls Clubs of St. Lucie County ( the Company ) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ( driving records ), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report and a copy of any report about you. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by: LexisNexis Screening Solutions Inc, P.O. Box 105108, Atlanta, GA 30348-5108, 1-800-845-6004 www.lexis.com/risk/solutions The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by LexisNexis Screening Solutions Inc. another outside organization acting on behalf of the Company, and/or the Company itself. LexisNexis Screening Solutions Privacy Policy: privacypolicy.lexisnexis.com/screen.html. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. Last Name: First: Middle: Signature: Date: ** If you will be requesting driving records, we recommend that you have this form notarized. Consumer Information Last Name: First: Middle Other Names/Alias: Social Security* # Date of Birth* Driver s License # State of Driver s License* Present Address Phone Number City/State/Zip Email Address: Please list previous addresses for last 7 years: Street Address City/State/Zip Street Address City/State/Zip *This information will be used for background screening purposes only and will not be used as hiring criteria.