VOLUNTEER Registration Form Kid's Day Out October 22, 2011

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Hosted by: IMPACT Autism @ UF
Date / Time: Sunday, October 22nd, 2011. 1- 4 pm
Location: Westside Park, Gainesville (1001 Northwest 34th Street Gainesville, FL 32605)
*At 12:30 pm we will be going over procedure for the event before the kids get to the park. We recommend you be there at 12:30 so you can receive information!

IMPACT Autism hosts Kid's Day Out events open to all children in the Gainesville Community. 2 volunteers are matched to 1 child and spend the day interacting with them in a fun and safe atmosphere. IMPACT will provide training to those volunteers who request it!

Directions: Please complete the following form to volunteer at this event to help us provide a good experience for you and the children.

***Note: This form is the FINAL step to be a volunteer. Before you begin, have you:
1. Paid your club dues?
2. Completed the HIPPA compliance and confidentiality statement?
http://privacy.health.ufl.edu/training/hipaaPrivacy/instructions.shtml
3.Completed your background check with Alachua County Sherriff's Office?
(for more details email us at impact.autism@gmail.com)

***Please know that if you commit to volunteering for an event we are counting on you to be there that day. Please only sign up if you are sure you can be there. If something comes up and you are unable to attend, PLEASE notify us so that we can make arrangements!

Name *

UF Student ID # *

Phone Number *

Email Address *

I have paid my IMPACT Autism dues for 2011-2012 *

Yes

I have completed my HIPAA and Confidentiality Statement online *

Yes

Background Check *

For the safety of our volunteers and children, I have completed an official background check

Yes

I will volunteer at the October 22, 2011 Kid's Day Out from 1- 4pm *

Yes

Do you need a ride to the event? *

Yes

Can you provide a ride to the event? *

Yes

Experience with children with autism or other disabilities

Experience is not required, but it is helpful for us to know any relevant experiences you might have working with children with autism or other disabilities. If you have described your experience in a previous KDO form and no changes have occurred, we already have your information recorded. Thanks!

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