Volunteer – Salem Adult Citizens

The goals of Salem Adult Citizens are best served through the active participation of community citizens. To this end, SAC accepts and encourages the involvement of volunteers within all appropriate programs, activities, and events. There are volunteer opportunities available for everyone 18 years and older, as well as volunteer groups from local corporations, organizations, and churches.

Become a volunteer by completing the application form below.

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Emergency Contact Information

Emergency Contact Name:

Emergency Contact Number:

Emergency Contact Email:

Emergency Contact Relationship:

Emergency Contact Address:

Address Line 1

Address Line 2

City

State

Zip Code

Volunteer Disclosure Statement:

I have not been convicted of any crimes or the attempt, solicitation, or conspiracy to commit any crimes, including those under Title 18 of the Pennsylvania Consolidated Statutes (“Crime Code”) or equivalent crime in another jurisdiction.
I have been convicted of or am pending indictment for the following crimes (include the dates, location, jurisdiction, circumstances, and outcome)

History of Criminal Activity:

Verification of Submitted Information:

Depending on the nature of the crime, I understand that my volunteer service may be terminated if I have a conviction. By signing below, I hereby swear/affirm that the information as set forth above is true and correct. I understand that the Penalty for false swearing is a misdemeanor of the third degree pursuant to Section 4903(b) of the Crimes Code.

Authorization for release of information

By signing below, I authorize Salem Adult Citizens to conduct background checks and obtain reports for use in connection with my volunteer application for volunteer services and/or for other related reasons. My authorization is ongoing and allows Salem Adult Citizens to obtain background information on me at any time during my volunteer work with the organization. I certify that I have read, understood, and agree to this Disclosure and Authorization form. On my request, I will be given a copy of this document.

Confidentiality Statement

Information about Salem Adult Citizens members, guests, and staff (including, but not limited to, medical, financial, personal, and legal data) is to be kept confidential. No information may be shared without the express written permission of the person in question. All donor information is considered confidential. All confidential information will be purged in accordance with regulatory guidelines.

I understand that during my volunteer service, I may be given access to confidential information. I understand that this information must not be shared or used outside of Salem Adult Citizens. In the event of my separation from volunteer service, whether voluntary or involuntary, I hereby agree not to utilize or exploit this information with any other individual or company.

Volunteer's Signature

Clear Signature

Application Reason

Date / Time of Completion:

Date

Time

Volunteer Application & Questionnaire

Applicant Information

Emergency Contact Information

Authorization for release of information

Confidentiality Statement

FOR OFFICE USE ONLY

Form Key:

() - Input Required*

Volunteer Application & Questionnaire

Applicant Information

Emergency Contact Information

Authorization for release of information

Confidentiality Statement

FOR OFFICE USE ONLY

Form Key:

(*) - Input Required

() - Input Required*