86 Centennial Loop Eugene, OR 97401
Tel: 541.484.5316 Fax: 541.484.1449 parentingnow.org
C:\Users\pcrown\Desktop\Volunteer Application Form 11-15 for Website.doc Updated: 11.10.2015
Statement of Confidentiality, Criminal Conviction Policy & Criminal Background Check
All information about Parenting Now! families is confidential. Staff and volunteers may have regular meetings to enable open discussion of any
concerns or problems. These meetings as well as telephone conversations or one-on-one contacts with staff are the appropriate ways to share
concerns of a confidential nature. Protection of the identity of group participants will be maintained within the group. All written files are strictly
confidential and contents are not to be disclosed. Casual disclosures to friends or family members are not only potentially harmful, but are also
illegal. Breach of confidentiality may result in dismissal. Parenting Now! is required to report child abuse to the State Office of Services to
Children and Families. Volunteers and staff members are responsible for privately discussing any out-of-the-ordinary behavior that they may
observe, with Parenting Educator or other site supervisor. Parenting Now! will run criminal checks on volunteers working with children and
families. I agree to a criminal background check per ORS 181.555 and ORS 181-560.
I understand and agree to comply with the above statement.
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Signature of Volunteer Date
Parenting Now! will run criminal checks on volunteers working with children and families. Please answer the following:
(1.) Have you ever been convicted of a crime involving offenses against children? Yes: ___ No: ___
(2.) Have you ever been convicted of a crime involving harm to another person, or any other offenses against persons? Yes: ___ No: ___
(3.) Have you ever been convicted of a crime involving dishonesty, theft or other offenses against property? Yes: ___ No: ___
(4.) Within the past 10 years, have you been convicted of a crime involving possession of a controlled substance? Yes: ___ No: ____
(5.) Have you ever been convicted of any other crime? Yes: ____ No: ___ If yes, please explain: ____________________________________
(6.) Have you ever been involved with DHS Child Welfare? Yes: ____ No: ___
(7.) Have you ever been involved with DHS Child Welfare & your case was considered “founded” or “unable to determine”? Yes: ___ No: ___
(8.) Have you ever lost custody of your children to DHS or another agency? Yes: ___ No: ___
Please note: A criminal record will not necessarily disqualify an applicant but will be considered as it relates to specifics of the position.
Are you under 18 years of age: Yes: ___ No: ___ How long have you lived in Oregon? ___________________________
Previous states you have lived in/dates you lived there. Please include the COUNTY you lived in: _____________________________________
Date of Birth: ________________ Soc. Security #: ________________________ Driver’s License # AND State: _________________________
Alias/Maiden Name: ______________________________________________________________
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Date: ____________Ref: _____________________By: ___________
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Please list two references who have knowledge of your qualifications (employer, instructor, etc., not personal friends/family/relatives)
1. Name: ____________________________________Phone: ________________________ Relationship: _________________________
2. Name: ___________________________________ Phone: ________________________ Relationship: _________________________
