PAS Richmond – Volunteer Registration Form

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Personal Information

RICHMOND PREJUDICE AWARENESS SUMMIT FACILITATOR APPLICATION

Please complete the application by October 7, 2022.
Please include your area code
Please include your area code
Please include your area code
Select from the drop down options

Demographic Information

Please provide the following demographic information. Be as specific as possible.
*This information will be used to ensure that we have as diverse a community at PAS as possible.*

Medical Information

Application Questions

Agreement

  1. I commit to being present at:
    • Facilitator Orientation – October 10, 2022 from 5:30 - 8:30 PM at the Glen Allen Public Library (10501 Staples Mill Rd, Glen Allen, VA 23060)
    • PAS – October 21, 2022 from 7:45 AM to 2:45 PM at VCU's Harris Hall
  1. I understand that although the Virginia Center for Inclusive Communities (“sponsor”) has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for the sponsor to guarantee absolute safety. I also understand that each participant/volunteer shares the responsibility for safety during all activities and I assume that responsibility for myself.  I waive any claim that may arise against the Board of Directors of the sponsor, and/or its employees, agents, volunteers, or lessors including those claims which may arise from the negligence of the sponsor, their Board of Directors; and/or its employees, agents, lessors or volunteers.
 
  1. I understand that volunteer facilitators are asked to complete a series of written evaluations that assess their views on the PAS program after the program.
 
  1. I understand that I, alone or with other participants and/or sponsor staff, volunteers, or representatives, may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) by the sponsor and/or others approved by sponsor.
 
  1. I understand that volunteers must maintain appropriate conduct and follow clear guidelines with all minors participating in PAS. Appropriate conduct and guidelines are outlined on the “Facilitator Code of Ethics: Professional Boundaries When Working with Minors” sheet.
 
  1. I certify that the information provided in this application is true and complete. I authorize the sponsor to investigate the facts presented in this application and to secure any necessary information from all employers, references, academic institutions, and other organizations.  I also agree to execute any additional written authorizations necessary for sponsors to obtain access to and copies of records pertaining to this information.  I agree to release any person, company, or other institution from any and all cause of action that otherwise might arise from supplying sponsors with information it may request pursuant to this release.
 
  1. I understand that acceptance of my offer of volunteer services to the sponsor is contingent upon receipt of satisfactory responses to any or all investigations conducted by the sponsor. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application, or for my immediate discharge if discovered after I begin providing volunteer services. I agree to comply with all applicable policies, procedures and rules of the sponsor, and I understand that any violation may result in my immediate dismissal as a volunteer.  I understand that nothing in this application, or in acceptance of my offer of volunteer services, is intended to create an employment contract between the sponsor and me.
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Sign on the line with mouse cursor or with your finger on a touchscreen. (NOTE: If you are on a desktop computer and are unable to see the signature line, please re-size the window so it is not full-screen and it should appear. This should not be an issue if you are submitting from your phone. If you are still having trouble please email [email protected].)
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