400 E. Sixth Street •Parkville, MO 64152

VOLUNTEER APPLICATION CHECKLIST The following items must be received before application can be processed:

Volunteer Application

Confidentiality Agreement

Missouri & Kansas background screenings ($20 total for both states) Synergy Services requires background screenings for both Missouri and Kansas.

Copy of Current Driver License

Copy of Social Security Card

(optional) Join Synergy’s Circle of Friends ($20)

PAYMENT INFORMATION

I prefer to donate on online at www.SynergyServices.org

My check for $ is enclosed (payable to Synergy Services)

(circle one) Visa Master Card Discover

Please charge my credit card in the amount of $

Card Number CVVS Exp. Date

Name on Card

Billing Address

City ST Zip

Signature

Please mail or fax

Synergy Services 400 E. 6th Street

Parkville, MO 64152 Fax 816-505-7176

For questions contact Judy Dale 816-505-4785

or JDale@synergyservices.org

Thank you!

400 E. Sixth Street •Parkville, MO 64152

VOLUNTEER APPLICATION

continued

We appreciate you taking the time to fill out this application. The information you provide will assist us in placing you in an appropriate volunteer opportunity that will match your skills and interests. Name: Age if under 18: Birthday: M_____D_____

Mailing Address Street City State Zip

Telephone: E-mail:

Drivers License State & # (copy is required):

Person to contact in case of an emergency: Phone: Please use the back of the page for any additional information to the following questions: Are you currently employed and/or in school? If so where?

Previous or Related Experience (work, school, volunteer):

How did you become interested in Synergy and what prompted you to become involved as a volunteer?

When are you available to volunteer (days of week & times)? How many hours per week/day are you looking to commit to? Please be as specific as possible.

Special or technical skills or training:

Are you associated with any Professional/Civic Organizations, clubs or organized groups? Please list:

Are you a member of Synergy’s Circle of Friends? □Yes □No If not, are you interested in learning more about the opportunity? □Yes □No Areas of Interest If possible, please indicate which opportunities you are most interested in:

Direct – Client Support Services (see job descriptions for details) □ Advocacy (Tutoring, YRC, General) □ Child Care □ Hotline/Intake Advocate

□ Mentoring (Parenting Teens, Women, Children) □ Outreach (Community Info/Special events)

□ Preparing/Cooking Meals □ Teaching groups (Life Skills, recreation, art, cooking, etc)

□ Women’s Advocate □ Other

Volunteer Application page 2 of 2

H:\Volunteers\Volunteer Application.doc 10/24/11

Indirect – Support Services

□ Clerical support (administrative duties, office aide, data entry, reception) □ Fundraising

□ House Keeping (cleaning and organizing) □ Public education and promotions □ Speakers Bureau

□ Special events □ Thrift Store (sorting, tagging, transporting items) □ Yard work

□ Special project in/around the building (painting, organizing, etc) □ Other

Please check skills and Interests that you would be willing to share in your volunteer experience:

□ Artistic □ Bilingual □ Career building/Resume □ Carpentry

□ Cleaning □ Data Entry □ Decorating □Event Planning

□ Filing □ Fundraising □ Gardening □ Grant Writing

□ Group Facilitation □ Hair Styling □ Heavy Lifting □ Landscaping

□ Legal Advice □ Microsoft Access / Excel / Publisher / Word (circle one or more)

□ Organizing □ Parenting □ Phone skills □ Public Speaking

□ Sorting donations □ Sewing/alterations □ Transport Safe Place Youth

□ Sign Language □ Other

References (please provide two references)

1. Name Relationship Telephone

Address City State Zip Email

2. Name Relationship Telephone

Address City State Zip Email

Authorization and Acknowledgement for release of information I acknowledge that Synergy Services, Inc. and/or its agents may investigate any information that it believes is business relevant including, but not limited to, employment history, educational background, criminal records, child abuse/neglect screening, police screening and driving record. I release any employees and persons named herein from all liabilities for any and all damages resulting from the furnishing and release of such information. I also authorize my former employers, schools and personal references to provide any information that would be relevant to performing the volunteer position they may have regarding me, whether or not it is in their records. I hereby release them and their company from all liability for divulging same. Signature Printed Name Date Thank you for your interest in Synergy Services, Inc. We understand there are many opportunities in the community for you to volunteer your time and talents. We appreciate that you chose Synergy and it is important to us that the experience will be mutually positive and rewarding.

Mission Statement “The Mission of Synergy Services is to strengthen the individual, family, and community

through crisis intervention, shelter, counseling, advocacy, and education.”

400 E. Sixth Street •Parkville, MO 64152

CONFIDENTIALITY AGREEMENT

H:\Forms\Confidentiality Agreement.doc 06/20/11

The mission of Synergy Services, Inc. is to eliminate family violence, abuse and neglect by providing quality services for persons of all ages. We seek to empower the individual, strengthen the family, and develop our community through crisis intervention, shelter, counseling, advocacy and education. Please initial each item and sign below to confirm your understanding and agreement. This Confidentiality Agreement is required of all board members, employees, independent contractors or business associates, and volunteers of Synergy Services, Inc. ______ Confidentiality of DV Shelter Location: My initials indicate that I understand the importance of safeguarding the location of Synergy Service’s domestic violence shelters. The confidentiality of domestic violence shelter locations is essential for maintaining the safety and well being of battered women and their children. I agree to not divulge the location of the domestic violence shelters except as necessary to conduct normal business operations. In the event that the location must be revealed, I agree to inform the party receiving the information about this policy and the need for confidentiality. ______ Confidentiality of Client Information: My initials indicate that I understand the importance of safeguarding the protected health information, including the identity, of clients of Synergy Services. I agree to take responsibility for the protection of client information and acknowledge that I am subject to sanctions and possible dismissal if involved in compromising client confidentiality. ______ General Agency Information Confidentiality:My initials indicate that I understand the importance of safeguarding confidential information, including Synergy Services Board and Committee members, volunteers, staff and consultants; donors, funders and beneficiaries. I agree to take responsibility for the protection of general agency information and acknowledge that I am subject to sanctions and possible dismissal if involved in compromising confidential Synergy Services information for any purpose. Signature: Date: Name: SS#: Please Print Organization: If Applicable Witness:

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES FAMILY CARE SAFETY REGISTRY

WORKER REGISTRATION

PLEASE TYPE OR PRINT CLEARLY

FCSR USE ONLY

SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)

CHILD CARE WORKER ($10.00) PERSONAL CARE WORKER($10.00) VOLUNTARY REGISTRANT ($10.00)

ELDER CARE WORKER ($10.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($10.00) FOSTER PARENT (NO FEE) SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING LAST NAME

FIRST NAME

MIDDLE NAME

MAIDEN NAME

PRIOR NAMES USED

SOCIAL SECURITY NUMBER (ATTACH COPY OF SOCIAL SECURITY CARD)

DATE OF BIRTH

GENDER MALE FEMALE

TELEPHONE NO. (optional) ( )

MAILING ADDRESS STREET ADDRESS OR POST OFFICE BOX

CITY

STATE

ZIP CODE

COUNTY

HOME ADDRESS (if different than mailing address) STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE) EMPLOYER NAME

CONTACT PERSON

PHONE NUMBER ( )

ADDRESS

CITY

STATE

ZIP CODE

SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to process this request. Furthermore, I authorize the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in §210.921, subsection 1, subdivisions (1) and (2), RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective employer/employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer of information to the FCSR within thirty (30) days of receiving the results of the background screening determination. NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my signature below authorizes my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds from your account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees. SIGNATURE OF APPLICANT (REQUIRED IN INK)

4 DATE

IMPORTANT • Individuals are required to register one time only. • Contact 1-866-422-6872 (toll-free) if you have questions or visit www.dhss.mo.gov/FCSR • Read back of form for instructions and information on registrant notification and appeal rights • Send completed registration form, copy of Social Security card and required fee to:

Missouri Department of Health and Senior Services Attn: Fee Receipts P.O. Box 570 Jefferson City, MO 65102

MO 580-2421 (FP)

WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provides families and other employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen child care, elder care and personal care workers and child care and elder care providers: 1. State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol 2. Child abuse/neglect records, maintained by the Department of Social Services 3. The Employee Disqualification List, maintained by the Department of Health and Senior Services 4. The Employee Disqualification Registry maintained by the Department of Mental Health 5. Child care facility licensing records, maintained by the Department of Health and Senior Services 6. Foster parent, residential care facility, and child placing agency licensing records, maintained by Department of Social Services 7. Residential living facility and nursing home licensing records, maintained by the Department of Health and Senior Services WHO HAS TO REGISTER? Any person hired on or after January 1, 2001, as a child care worker or elder care worker, or hired on or after January 1, 2002 as a personal care worker, as defined in §210.900, subsection 2, RSMo, is required to make application for registration in the Family Care Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration form to the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and volunteers from non-State and/or Federally regulated entities are NOT REQUIRED to register with the FCSR. HOW DO I COMPLETE THE REGISTRATION FORM? Section A: Type of Worker - Check one box that best describes your worker category. A "voluntary registrant" is a person who is not mandated to register with the Family Care Safety Registry pursuant to §210.900 to §210.936, RSMo.

Section B: Identifying Data for Background Screening - List your current name, maiden name, all prior names used, Social Security number, date of birth, gender, home address, and mailing address. You must provide your Social Security number pursuant to §210.906.2, RSMo Supp. 1999. This identifying information, including Social Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above.

Section C: Current Employer Information (If Applicable) - If you are currently employed by or are seeking employment with a child care or elder care provider, please list the facility name, owner/operator, telephone number and facility address. If you are a foster parent, a voluntary registrant, or receive state or federal funds for child care or elder care services, leave this section blank.

Section D: Authorization to Release Background Check Information - Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background screening outlined in §210.903.2, RSMo and to provide the information to requestors for “employment purposes”, as provided in §210.921.1, RSMo. WHERE DO I SEND MY REGISTRATION FORM? Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior Services, Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102. If you have questions, please call the Registry using the toll-free telephone number, 1-866-422-6872. WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND CHECK? After the background screening has been completed, you will be notified in writing of the results that will be recorded in the Family Care Safety Registry. You will also be notified in writing each time background screening information is provided. The notification will contain the name and address of the person who made the request and the background information disclosed. The person making the request will be informed that information will be released for employment purposes only as defined pursuant to §210.921.1, RSMo. Any person using Registry information for any other purpose is guilty of a class B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and address of the person calling, and determines that the request is for employment or regulatory purposes. To ensure you receive these notifications, it will be important for you to notify the Family Care Safety Registry when you have a change in your mailing address. You can send address changes to Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102. WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND CHECK? Pursuant to §210.912, RSMo, you have the right to appeal the information transferred onto the Family Care Safety Registry. Your right to appeal is limited only to the accuracy in the transfer of information from the state agency that maintains the background information and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal needs to be filed in writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O. Box 570, Jefferson City, MO, 65102, within 30 days of receiving the results of the background screening determination. An administrative appeal shall be set within 30 days of the filing of the appeal and a decision shall be made within 60 days. This right to appeal is in addition to any other appeal rights granted by state law. WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY? Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. A Registry worker will first confirm whether the person in question is registered. If the person is registered, the Registry worker will then disclose whether the person's name is listed in any of the background checks pursuant to §210.903, subsection 2, RSMo, and if so, which one. Specific information will only be disclosed by the Registry upon receipt of a written request from the caller. MO 580-2421 (FP)

CFS 1011

January 2010

Page 1 of 1

Kansas Department of Social and Rehabilitation Services

Child Abuse and Neglect Central Registry

915 SW Harrison 5th Fl. South

Topeka, Kansas 66612

Child Abuse and Neglect Central Registry

Release of Information

I, ________________________________, give permission for the release of any information concerning (please print complete first, middle and last name) myself in the Child Abuse and Neglect Central Registry to:

Contact Person:

Agency Name:

Mailing address:

Phone Number ( )

I understand that all information released will be for the exclusive and confidential use of the above

named organization/person/agency.

** Please complete the information below by printing in ink. Please print legibly. Do not leave

any space blank. All requested information is required to process this request. Incomplete

information will result in the release not being processed and will be returned as insufficient.**

First, Middle and Last Name:

Maiden Name: (Female applicant only)

Married Names, Nicknames or Other Names Used: (Use N/A if no other names used)

Date of Birth: Race:

Social Security # Gender: ☐ Male ☐Female

Signature: Date:

Current Address:

Each request must be submitted with payment prior to the request being processed. Please attach appropriate fee of

$10.00 per release of information. All releases and fees should be sent via postal mail to the attention of SRS, Child

Abuse and Neglect Central Registry, P.O. Box 2637, Topeka, KS 66601. The following state agencies are exempt

from the $10.00 fee: JJA (Central Office or Facilities), KNI, Dept. Of Education- Central Office, KDHE, State

Hospitals, State Correctional Institutions, Attorney General’s Office, Kansas School for the Blind, Kansas School for

the Deaf, Child Welfare agencies in other states. Mentor record checks, i.e. Big Brothers Big Sisters, are exempt

from the $10.00 fee. For a complete list of Mentor Programs, go to: http://kansasmentors.kansas.gov/Pages/FindaProgram.aspx.

If this is a mentor record check, please make sure the box below is checked. Mentor Program: ☐ If yes, please check

For Central Registry Use Only

_____ FEE ATTACHED