PART 1: ALL VOLUNTEERS, INTERNS, OR JOB CANDIDATES (*)
Information About You
Address (*)
Birth Date (MM/DD/YYYY)
Primary Language (*)
Secondary Languages
References
Your First Reference
Your Second Reference
First Name(*)
Last Name(*)
Your Third Reference
PART 2: ALL VOLUNTEERS: YOUR VOLUNTEER INTERESTS (*)
PART 3: EMPLOYEE INTEREST
I am interested in being hired as an adoption worker
I am interested in being hired for the mentor program
I am interested in being hired for the web program
I am interested in being hired for the Admin program
I am interested in being hired for the Event or Development programs
I am interested in being hired for any AFFEC role
PART 4: ALL VOLUNTEERS: CONFIDENTIALITY STATEMENT (*)
I have read and agree to the following:
AFFEC Volunteer
Statement of Understanding
and Confidentiality
Confidentiality and Privacy Policies
I understand that, as an AFFEC volunteer, I am subject to the same rules and laws of confidentiality
that apply to paid staff. I agree to keep confidential any and all information concerning all persons
served by AFFEC, including children birth parents, and prospective adopting parents, and including all
DHS clients. I will not divulge to any outside person or agency any confidential information about
any such person, unless I am specifically authorized to do so by AFFEC. “Confidential information”
includes, among other things:
the name, address, photo, or other identifying information about such persons;
the fact that such person is working with AFFEC;
any information contained in such person’s file; and
any financial, medical, marital, or health information about such person.
I understand that I must keep this information confidential at all times and even after my period of
volunteer service ends.
I further agree to act in a responsible and professional manner when providing services to clients in
an AFFEC program, and agree to adhere to the policies governing ethics and conduct of AFFEC and
the State of Oregon.
All records dealing with specific clients must be treated as confidential. Although the agency is liable
for your acts within the scope of your duty, giving information to an unauthorized person could be
interpreted as not acting within the scope of duty and the agency could refuse to support you in the
event of legal action. Violation of Oregon Revised Statute regarding confidentiality of records is
punishable upon conviction of a fine of not more than $1000 or by imprisonment in the county jail for
not more than 60 days, or both.
Reporting Requirements
I understand that I am required to keep track of my hours of service. A time sheet will be submitted to the AFFEC/Program Director each month.
Conflict of Interest
If at any time I become aware of a conflict of interest, including knowledge of any persons I may
know who are involved in a case that may be assigned to me, I will notify the Director of
AFFEC/Program Director immediately.
As an AFFEC volunteer, I shall not take any action that would result in personal financial benefit. I
will not ask for or receive for myself or for any member of my household, directly or indirectly, any
monies or gifts from clients.I agree to not use any information gathered or shown for my own personal benefit.
I understand that all information is privileged and confidential and agree to treat it as such; not using anything for
personal gain. I understand that if I am given access to AFFEC's database (that carries case related
information as well as child listings), I agree to not use it for personal gain, i.e., my own child
searches. Evidence of such will be grounds for immediate dismissal.
Further, I understand that volunteer, work experience, intern and practicum service does not in any
way assure me of any future position as an employee of AFFEC or DHS, nor does it entitle me to any
benefits of regular employment, such as salary, medical or dental insurance or any other incident of
regular employment.
Personal Professionalism
I agree to attend orientation and training sessions and meetings as required. High ethical standards
are essential to the maintenance of public trust and confidence in our program. Volunteers shall
therefore maintain a professional standard of conduct and shall not engage in conduct that would
bring discredit upon the AFFEC or DHS.
Mandatory Abuse Reporting
As Agents of the State, volunteers must, by law, report any suspected child and elder abuse. Anyone
making such reports in good faith shall have immunity from any liability, civil or criminal.
I understand that the A Family for Every Child may terminate or modify the terms of this work
agreement at any time. My signature below certifies that I have read and understand all information
presented in the agreement points presented in this document. I understand that my duty as an
agent of AFFEC and DHS is to abide by the laws of Oregon and policies of both agencies, including
preservation of confidential information, including PHI (Protected Health Information).
Confidentiality Statement Signed
Please type in your name to indicate that you agree.
PART 5: ALL VOLUNTEERS: AUTHORIZATION FOR RELEASE OF INFORMATION (*)
Interests
AUTHORIZATION FOR RELEASE OF INFORMATION / PRIVACY ACT NOTICE
A FAMILY FOR EVERY CHILD
1675 West 11th Avenue - Eugene, Oregon 97402
(541) 343-2856 / (541) 343-2866 FAX
www.afamilyforeverychild.org
PLEASE READ THE DISCLOSURE BELOW: CHECK THE BOX TO INDICATE AGREEMENT.
In checking this consent form below, you are authorizing A Family For Every Child to request information from the sources you are providing for verification purposes. A Family For Every Child will not sell nor solicit your private information to outside sources. This authorization is valid for five years from the date of this form's submission.
I hereby authorize all former employers, persons, educational institutions, law enforcement agencies and
military services to release information related to my work record or in reference to information provided and
release them from any liability or responsibility from doing so. I understand that omitting or giving false
pre-employment information is reason for disqualification or dismissal and that an offer of voluntary placement
is subject to verification of employment history satisfactory to A Family For Every Child .
www.afamilyforeverychild.org
.
I understand that this request is due in part because of the business partnership contract between
A Family For Every Child and the State of Oregon – Department of Human Services ,
primarily Child Welfare .
Consent for Release of Information
PART 6: FOR Photography VOLUNTEERS
Statement of Agreement
Heart Gallery Photographer’s Statement of Agreement
I, (Your Name Printed)
as a photographer for A Family For Every Child / Heart Gallery hereby state that:
I understand that I am providing a charitable service to A Family for Every Child - Heart Gallery for the purpose of photographing children who are in need of adoptive families.
I agree to be in compliance with all federal and state regulations concerning children, including but not limited to laws concerning abuse and neglect, confidentiality, and child pornography.
I certify, under penalty of perjury, that I am not a convicted felon, nor under suspicion of committing a felony. I further certify, under penalty of perjury, that I have never committed a crime, and am not under suspicion of committing a crime, involving a child.
I understand that I cannot use these photographs or any representation of the photographs for any other purpose, including but not limited to advertising, on line portfolios, web sites or displays. I may not use these photographs in any way without signed consent from the individual states Department of Human Services. However you are welcome to use our logo and link our site, so your visitors know of your services provided, we are happy to provide our logo, and would welcome yours on our site.
I agree to keep confidential any information that I might learn of these children, including such information as current residence, date of birth, last name, school, or any other identifying information. I further agree to be in compliance with all federal and state regulations concerning the confidentiality of this information.
I understand that A Family for Every Child - Heart Gallery and/or any representative or contractor of the Department of Human Services may use the photographs I have taken, without further permission from me and for any use deemed appropriate by the aforementioned entities. I further understand, however, that those entities will not sell the photographs except in a context that promotes A Family for Every Child - Heart Gallery, such as a commemorative book.
I understand that I cannot hold A Family for Every Child - Heart Gallery and/or any representative or contractor or the Department of Human Services liable for any accident or injury to me or to my property that might occur while photographing the children.
I agree to take the photographs that, to the best of my ability, highlight the children themselves, fully understanding that the purpose of these photographs is to enable “heart connections” to be made with prospective adoptive families. I agree that if a choice must be made between highlighting my artistic skills, and highlighting a child’s personality, I will choose to highlight the child’s personality.
I understand that given the nature of the endeavor, I am given no guarantee that my photograph(s) will be displayed or used for recruitment. I understand that there are reasons beyond my control for which a photograph might not be displayed, to include adoption before release of photographs, or a change in the child’s status.
I understand that I am bound by all the provisions set out in this agreement and failure to comply with any provision will subject me to any damages or remedies that may be available to the Department of Human services or the A Family for Every Child - Heart Gallery.
I understand that this agreement shall be forever binding.
Agreed to this 9th day of June, in the year 2023.
X (Your Signature)
(spell out your signature to indicate you agree)
Photograper's Studio Name
Photographer's Studio Phone Number
Videographer
I have a photography studio
I speak Spanish
I am willing to travel:Will not travel Will travel more than 50 miles Will travel up to 20 miles Will travel up to 50 miles
PART 7: FOR Family Finding VOLUNTEERS
Interests
Step(s) Interested InWhy are you interested in volunteering with Family Finding?
PART 8: FOR Mentoring VOLUNTEERS
Interests
You should try to answer, but not worry about answering, all of these questions since they will be addressed
in your interview. Please avoid punctuation like & and < and > .
Special needs/Accomodations
What is your favorite subject in school?
Which subject is most challenging?
Would you like to wk on hw with child?
Do you have a favorite sports team?
if you participate in sports, which onesOutdoor activities you participate in?
Indoor activities you participate in?
Are there any new activities you're interested in trying?
Favorite Type of Food
What are your favorite restaurants? How do you express yourself?What makes you laugh?
What types of movies do you like?Do you like to read? Which books
How do you spend time with your friends?
If you had a free day where would you go
How do you spend vacations/summer?
One place you would like to visit
What is something you work hard at?
What are you most proud of?
How would you describe yourself?
Who helps you when you have a problem?
Do you have a hero? Who?
What do you like to talk about?
Do you like to sing or dance?
Anything you want to teach/give lessons?
How do you like to celebrate holidays?
What is your favorite holiday?
What animals do you have?
What animals do you like or would like?
What is your least favorite chore?
What is your favorite chore?
Favorite Thing about where you live?
Most challeng thing about where you live
If you had 3 wishes what would they be?
What makes you sad?
What embarrasses you
What would you like your mentee to know
Best thing that has happened in life?
Why are you interested in being a mentor
What does "being a mentor" mean to you?
Connect better w/boys or girls? Why?
What age group best suites you?
Did you have good mentors/role models?
Activities done with your mentor?
Any behaviors you find challenging?
Skills willing to teach older kids?Interested in adoption or foster care?
What skills or traits could you bring to the table that make you a good mentor?
Do you speak multiple languages? Which ones?
What activities would you like to do with your mentee?
Would you prefer to work with a more outgoing or reserved child?Outgoing Reserved Do you anticipate any changes in your residency, employment, etc. that may affect your potential mentorship?Yes No Have you previously applied with this agency, or another mentoring agency? What affected the duration of your participation?
Have you ever been arrested, convicted of a crime, committed a crime against children, or been deemed a suspect person by a child welfare agency?Yes No Have you lived anywhere else in the last 5 years? If so, please list where and why you relocated.
Other Hobbies, Skills or Interests
Past Work and Volunteer Information
PART 9: FOR Parent Mentor VOLUNTEERS
Interests
You should try to answer, but not worry about answering, all of these questions since they will be addressed
in your interview. Please avoid punctuation like & and < and > .
1) What sparked your interest in becoming a parent mentor?
2) What life experience do you think qualifies you to mentor an at risk parent? Education, life experience, or a mix of both?
3) At some point everyone has faced adversity in some way. Name one time you faced adversity and overcame it. What lessons did you learn and what lessons could you potentially pass on to a parent in need?
4) What activities do you like to do in your spare time?
5) Growing up, who was your biggest influence, either positive or negative?
6) What skills do you possess that you feel would be most beneficial to a family in our program?
7) Have you even been involved with DHS or law enforcement in the past, either positively or negatively? Please keep in mind that this will not necessarily disqualify you from participating in the program, in certain cases it may work to an advantage as you are in a position to relate to a family that may be involved currently.
8) Where do you see yourself in 10 years?
9) What do you consider “successful”?
10) How do you generally make new friends?
11) Do you have any special accommodations that need to be taken into consideration when matching you with a parent (medical, religious, political, or other)? We want to ensure that we are as accurate as possible when matching parents and mentors to ensure optimum success.
12) What is your highest level of education?
13) Are you willing to attend trainings with your parent mentor as well as alongside other fellow mentors?
14) What is a pet peeve of yours?
15) Are you a member of any community organizations, nonprofits, or anything else that would be of use to a parent in need?
16) Do you hold professional licensing (CPA, MSW, attorney, DR, auto mechanic, building contractor, etc) that could come in handy for a parent mentor?
17) What is your idea of appropriate personal and professional boundaries?
18) Do you think you would be comfortable visiting a parent living in a homeless shelter or alternative living situation? Could you remain neutral and non-judgmental?
PART 10: VOLUNTEER TO PROVIDE A HOST HOME
Interests
You should try to answer, but not worry about answering, all of these questions since they will be addressed
in your interview. Please avoid punctuation like & and < and > .
1) Why are you interested in becoming a Host Home?
2) What experience do you have with youth?
3) What are resources you could provide a youth in your home (example - food, clothing, education assistance, etc.)?
4) Can you pass a background check?
5) How many people are living in your home? What are their names/ages?
6) Do you have any pets? If so, what kind?
7) How did you find out about the Host Home Program?
PART 11: YOUR QUESTIONS AND COMMENTS
Please write any questions or comments into the box below.
Volunteer Comments