Please review the information below carefully.  You may print this form, sign it and bring it to your inverview, or one will be provided to you during your interview.  Thank you!

VOLUNTEER CERTIFICATION

1.  I certify that the answers and information provided in the Volunteer Application are accurate and complete to the best of my knowledge.  I acknowledge that if any of the information provided is not accurate or complete, I may be denied the opportunity to provide volunteer service.

2.  I authorize the Urbandale Caring Corps to investigate all statements contained in this application for volunteer service, as well as my character and qualifications.  I release the Urbandale Caring Corps from all liability for acts performed in good faith in connection with said investigation and evaluation of my application.

3.  I understand and agree that I am not employed by the Urbandale Caring Corps, and that the relationship between the Urbandale Caring Corps and me may be terminated at any time by either party.

4.  I understand and agree that as a volunteer I must conform to all of the Urbandale Caring Corps rules and regulations, including those in the Volunteer Orientation Manual.

5.  I understand that information I have provided on my volunteer application is confidential.  I further understand and agree that information I obtain or learn while assisting a client shall also remain confidential.

6.  I understand and agree that if I will be driving clients, I must provide a copy of my current driver's license and auto insurance coverage to the Urbandale Caring Corps.  I further understand and agree to provide updated copies of my license and insurance coverage each year I am a volunteer driver.

7.  I hereby certify that I DO NOT have a record of founded child and/or dependent adult abuse.

8.  I hereby certify that I have never been convicted of a serious misdemeanor or a felony.

Signed this ______ day of _____________, 200___.

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