CornerStone Adult Volunteer & Background Check (18 years old +)
THIS FORM MUST BE COMPLETED AND SIGNED BY THE QUALIFYING VOLUNTEER OR STAFF MEMBER.
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Email *
Legal First Name: *
Middle Name: *
Last Name: *
Preferred Name (if not first):
Phone Number *
Additional ways to contact if applicable:
Date of Birth: *
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DD
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Current Address: *
Emergency Contact Name:
Emergency Contact Relation:
Emergency Contact Phone Number:
Background Check
THE FRAZEE POLICE DEPARTMENT REQUIRES THIS INFORMATION AND CONSENT TO CONDUCT CRIMINAL HISTORY CHECKS.
Additional Names (if applicable):
Driver's License State and Number: *
Certification & Authorization
  CERTIFICATION AND AUTHORIZATION: 
_______ I, the undersigned, have made application to CornerStone Community and Youth Center for a position or volunteer activity working directly or closely with youth. 
_______ I certify that complete and accurate responses have been provided for all questions on the application. 
_______ I hereby request and authorize the Frazee Police Department to conduct a background check of me through their records for safety purposes.  
Liability Waiver

I agree to abide by the policies and regulations set by CornerStone. I understand that violations of these, or misrepresentation of information on this form, may result in restriction, revocation, reduction or loss of program volunteer status.    

I hereby waive and release CornerStone, its officers, agents and employees, from and against any claims, suits, losses, or related causes of action for damages, including attorney’s fees and court costs, that may result from injury or death, accidental or otherwise, during, or arising from my participation in a volunteer activities, including transportation to and from activities associated with the program, and any resulting illness and/or injury, and I agree to indemnify and hold harmless CornerStone from and against any and all such claims. I recognize that recreational events or other volunteer activities being entered into can pose possible dangers and I accept those dangers. I understand that if I am injured, this waiver will be used against me and anyone else claiming damage in any legal action because of my injury. I hereby acknowledge that I understand and am familiar with the nature of the activities in which I will participate at this facility.  I also understand that I should have health and accident insurance to cover injuries arising from participation in volunteer activities.  

In case of emergency, I give my permission for my emergency medical treatment if I am unable to access it myself and for transportation to such treatment.   

I certify the accuracy of the information in this application.  By signing this form I understand that, as a CornerStone volunteer, I will be an important part of the CornerStone team and am expected to uphold the Vision, Mission, Values and policies/procedures of the organization to maintain my volunteer status.    I authorize CornerStone staff to verify information in this application and contact references listed.  I release all parties from liability for any consequences that may result from furnishing information to CornerStone staff.  I understand that because of CornerStone’s commitment to keeping youth safe from harm, that some volunteer work may require an additional background check and possible interview to ensure appropriate methods have been taken to preserve the health and welfare of all youth participants. 

________ I, the undersigned, have read, understand, affirm, and agree to the above statements. 

Media/Photo Consent

I understand that CornerStone workers are authorized to use and publish photos of youth participants and workers in print or electronically on behalf of the organization.  

I understand that CornerStone may use such photographs with or without my name for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content. I will make no monetary or other claims against CornerStone for the use of such photos/videos. 

_______ I affirm I have read and understand the above and I grant CornerStone permission to take photographs of me.

The name of the qualifying individual below will indicate an electronic signature consenting and agreeing to thee above statements. *
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