Aspiring
Volunteer Application
Name: Preferred Mailing Address:
Phone: Fax: Email:
How did
you hear about Aspiring Youth?
Education:
High School/ GED
Information
required for background check:
Social Security Number: Birth date:
Race: Gender:
Have you ever been arrested or convicted of a Felony? Yes No If yes, please list the Felony(s):
Have you ever been arrested or convicted of a Misdemeanor
(other than minor traffic violations)?
Yes No If yes, please list the
Misdemeanor(s):
Have you ever been given a Deferred Adjudication sentence
that has not yet been successfully completed (other than minor traffic violations)? Yes No If yes, please list:
I, , acknowledge and agree that all information given on this application is true and complete to the best of my knowledge and I have read the Speaker Guidelines and agree to meet them in return for the ability to serve as a volunteer. My permission is given for both reference and criminal background checks. I understand that Aspiring Youth® will not disclose my social security number to any third party, except as necessary to conduct a criminal background or reference check, or as otherwise required by law. Furthermore, results of the criminal background or reference check will not be disclosed to any third party, except as otherwise required by law.
I HEREBY GIVE MY PERMISSION FOR
GOOD AND VALUABLE CONSIDERATION FOR ASPIRING YOUTH OF HOUSTON TO OBTAIN
INFORMATION RELATING HISTORY RECORD THROUGH VOLUNTEER HOUSTON. THE CRIMINAL HISTORY RECORD, AS RECEIVED
FROM THE REPORTING AGENCIES, MAY INCLUDE ARREST AND CONVICTION DATA AS WELL AS
PLEA BARGAINS AND DEFERRED ADJUDICATION.
I UNDERSTAND THAT THIS INFORMATION WILL BE USED, IN PART, TO DETERMINE
MY ELIGIBILITY FOR AN EMPLOYMENT/VOLUNTEER POSITION WITH THIS
ORGANIZATION. I ALSO UNDERSTAND THAT AS
LONG AS I REMAIN AN EMPLOYEE OR VOLUNTEER HERE, THE CRIMINAL HISTORY RECORDS CHECK
MAY BE REPEATED AT ANY TIME. I UNDERSTAND
THAT I WILL HAVE AN OPPORTUNITY TO REVIEW THE CRIMINAL HISTORY AND A PROCEEDURE
IS AVAILIABLE FOR CLARIFICATION, IF I DISPUTE THE RECORD AS RECEIVED.
I, THE UNDERSIGNED, DO, FOR
MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, HEREBY REMISE, RELEASE AND
FOREVER DISCHARGE AND AGREE TO INDEMNIFY AND DEFEND VOLUNTEER HOUSTON AND EACH
OF THEIR OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS HARMLESS FROM AND AGAINST
ANY AND ALL CAUSE OF ACTIONS, SUITS, LIABILITIES, COSTS, DEBTS AND SUMS OF
MONEY, CLAIMS AND DEMANDS WHATSOEVER, AND ANY AND ALL RELATED ATTORNEY’S FEES,
COURT COSTS, AND OTHER EXPENSES RESULTING FROM THE INVESTIGATION OF MY
BACKGROUND IN CONNECTION WITH MY APPLICATION TO BECOME A VOLUNTEER/STAFF
MEMBER. THIS INDEMNIFICATION DOES NOT
INCLUDE ANY GROSS NEGLEGENCE OR INTENTIONAL TORTIOUS CONDUCT ON THE PART OF THE
VOLUNTEER CENTER.
____________________________ ___________________________ _____________
Volunteer’s
Signature Volunteer’s Printed Name Date
(If sending by e-mail, we will get you to sign it later)
If you have any questions or need any additional
information, please contact Chris Ramirez, at 713-334-3330 (ext.307). For information on Aspiring Youth, see www.aspiringyouth.org.
Thanks for
your assistance in expanding the horizons of
Please fax this form to Chris Ramirez at fax: (713) 334-3366 or by E-mail to cramirez@aspiringyouth.org
or by mail to Aspiring Youth of
6250 Westpark,