Dear Applicant, Thank you for your interest in the Child Study Center ...

Dear Applicant,Thank you for your interest in the Child Study Center Adult Volunteer Program.The time and dedication put forth by the volunteers at the Center plays a crucialrole in bringing potential to light for children with development disabilities. Fornearly 50 years, the Child Study Center has provided diagnosis and treatmentservices to children who have, or are at risk for developmental disabilities, relatedbehavior and emotional problems so that these children may achieve their fullpotential.In order to begin the application process, please complete and return the attachedforms. Once received, you will be contacted to set up an initial interview. Theforms may be submitted either by:Mail: Child Study CenterAttn: Foundation Dept.1300 West LancasterFort Worth, TX 76102Fax: 817-870-2116Forms to be returned: Volunteer Application Volunteer Placement Positions Volunteer Confidentiality Agreement Volunteer Background Release FormThank you for your desire to serve the children and families of the Child StudyCenter. If you have any questions, please contact us at 817-390-2804 or emailvolunteer@cscfw.org.

Office Use Only:Date received: ___________Entered by: _____________Interview date: ___________Volunteer ApplicationThe Child Study Center provides diagnosis and treatment services to children who have, or are at risk fordevelopmental disabilities, related behavioral and emotional problems so that these children may achieve their fullpotential.(PLEASE PRINT)Last Name First Name Middle InitialStreet AddressApartment NumberCity State Zip CodeHome Phone( )Cell Phone( )Work Phone( )E-mail AddressDate of birth Male or Female Spouse’s NamePlease circle all that apply.High School Graduate College Graduate Graduate School Graduate Other _____________Present or last place of employment: Phone: ( )Describe job duties:Volunteer ExperienceList current or previous volunteer activities you have been involved with.Name of organization Types of duties performed Date1.2.3.Please explain your interest in volunteering at the Child Study Center.Are you required to complete volunteer hours? YesNoHave you ever volunteered at the Child Study Center? YesNo

Emergency Contact NameEmergency Contact Phone Number( )Relationship to ApplicantList allergies and any other health concerns staff should know.Personal Reference #1 (may not be a family member)Name: _____________________________________Personal Reference #2 (may not be a family member)Name: _____________________________________Phone: () _______________________________Phone: () _______________________________AUTHORIZATION AND ACKNOWLEDGEMENTI understand that the Child Study Center has the right to verify employment and volunteer experience as listedon the previous pages. I also understand that the Child Study Center will check my professional/personalreferences as listed on the previous page. I understand that information relating to my character, work habits,performance and experience may be requested of my professional/personal references, if applicable.I CERTIFY that all of the above information is true/correct to the best of my knowledge and authorizeinvestigation of all statements. Any misstatement/omission of fact in this application may result in mydismissal. I understand that volunteer acceptance does not create a contractual obligation upon the Child StudyCenter to continue my opportunity for volunteering in the future.SIGNATURE __________________________________________DATE ________________________

Volunteer Placement PositionsThe positions listed below are categorized according to department. Please review and place a check (√) in thebox next to each volunteer position that interests you.APPLIED BEHAVIOR ANALYSISChild Tutor - work with children with autism (4-8 hrs daily)Curriculum Prep – download, laminate, and cut pictures from the internet; Excel & MS Word necessaryADMINISTRATION/OPERATIONSHostess – help with Committee/Board meeting setupOffice Assistant (Operations) – data entry, printing documents, organizing paperwork, some technology tasksCLIENT SERVICESClient Services Assistant –assist with application process, filing, and call patients regarding appointment time(Tues/Thurs/Fri)Front Desk - assist with patient check in/checkout procedures (a.m./p.m. daily)Switchboard Operator Assistant - answer phones, run/sort mail, direct visitors to clinicMedical Records Assistant- microfilm filing, scanning, checking chart names and numbersFOUNDATIONSpecial Events – assist with annual Children’s Golf Classic, Party on the Patio, Puzzle Scuttle, Experience thePotential (seasonal)JANE JUSTIN SCHOOLOffice Assistant – data entry, die cutting, printing, copying, collating (4 hours per week)Bulletin Board Designer – remove and set up new displays for classrooms (1 day per month)Book Fair Attendant – manage the Point of Sale (4 hour shift, Monday-Friday, one week in the fall & spring)Lunch Monitor – monitor students as they eat, clean up spills, teach good manners (11:00-12:30 daily)Filming Assistant – record, download and edit video (1 day per quarter)Drive through Monitor – provide a visual presence & monitor traffic in the drive through (2:45 – 3:15 p.m. daily)Classroom Play Attendant – actively engage in play activities, promote sharing, teach cleaning up (a.m./p.m. daily)Volunteer Tutor – assist students as they complete reading, math and language assignments (a.m./p.m. daily)PEDIATRICSResearch Assistant – data collectionStudent Intern – interested in completing rotation necessary for degreeMedical Assistant- interested in screening patientsPSYCHOLOGYClerical Assistant – general filing, clerical

Volunteer Confidentiality AgreementAs a Child Study Center (CSC) Adult Volunteer, I understand that I will be in contact with informationpertaining to clients who have been, who are, and who will be receiving treatment from the services we provide.I also understand that all client information is of a confidential nature and will not be given or discussed withthose who are not authorized to receive this information. In addition, client information may not leave CSCpremises except through established policies and procedures.Finally, I understand that should I violate the clients’ right to privacy, my relationship with CSC is subject toimmediate termination.SignatureDate

Volunteer Background Release FormAGENCY INFORMATIONDateAgency NameContact NameAgency’s Main Phone NumberAgency’s Fax NumberAPPLICANT INFORMATION:Applicant Full Name (Last, First, MI)Maiden or Other Name(s) UsedCurrent AddressCity State Zip Code CountySocial Security Number Date of Birth Driver’s License Number State IssuedPosition Applied ForGender Male Female Race African American American Indian Anglo Asian Hispanic OtherI hereby authorize VERIFYI and or its Service Provider to request and receive any and all background information about orconcerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumerreport under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, CivilListings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law EnforcementAgency, and other entities including my Present and Past Employers.The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as pleabargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this informationwill be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I alsounderstand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at anytime. I understand that I will have an opportunity to review the criminal history as received by client/agency and aprocedure is available for clarification, if I dispute the record as received. I also understand that the criminal history couldcontain information presumed to be expunged.I further release and discharge VERIFYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers,Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request forinformation or records pursuant to this authorization, procurement of an investigative consumer report and understandthat it may contain information about my character, general reputation, personal characteristics, and mode of living,whichever are applicable.I understand that I have the right to make written request within a reasonable period of time to VERIFYI for additionalinformation concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided theabove information for employment/volunteer purposes, and I have carefully read and understand this authorization.Applicant’s SignatureDateApplicant’s Printed NameParent/Guardian’s Signature (if under 18 years of age)