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----eAHOWMUd;NSvBZB Dear Prospective Volunteer, Thank you for your interest in the Volunteer Program at Texas Scottish Rite Hospital for Children. We have certain requirements that must be completed before volunteering. Please provide a copy of the items listed below. APPLICATIONS WILL NOT BE ACCEPTED WITHOUT THE FOLLOWING INFORMATION: Volunteers born after 1956 must provide proof of immunity or immunization to ALL of the following: □ MMR #1 & #2 (Measles or Rubeola, Mumps and Rubella)– 2 shots totaling 1mL □ CHICKENPOX #1 & #2– Proof of varicella vaccines (2 shots) or proof of disease from treating physician □ TDAP (Tetanus, Diphtheria and Acellular Pertussis)– TDAP vaccinations must have been given within the last 10 years Volunteers born in or before 1956 must provide proof of immunity or immunization to: □ TDAP (Tetanus, Diphtheria and Acellular Pertussis)– TDAP vaccinations must have been given within the last 10 years Two completed reference questionnaires: □ Please ask two individuals to complete the attached reference questionnaire. Your references need to be 18 years of age or older and have known you for at least two years (no relatives please). Questionnaires must be included with your application in a sealed envelope with the reference's signature across the seal. Thank you for your cooperation and support. We look forward to meeting you! Sincerely, The Volunteer Services Staff Completed applications may be dropped off or mailed to: Scottish Rite for Children Attn: Volunteer Services 2222 Welborn Street, Dallas, Texas 75219 214.559.7825 For Office Use Only: Called for interview: _______ _______ _______ Invited to orientation: ________ ________ ________ Interviewed on: _________ Attended orientation on: ________ Flu: TB: App made incomplete: _______ ( Letter Mailed) FOR OFFICE USE ONLY: Revised: 1/2020 Date Received: __________________ MMR: CP: Tdap: Refs: VSys: Email: Background Check: Input: Clear: Dallas Frisco Reviewed: ___________ Assigned to: __________ ADULT VOLUNTEER APPLICATION (Ages 18+) Applications will not be accepted without proof of immunizations & references PERSONAL INFORMATION: Title: _____ Last Name: ___________________________First Name: _______________________Middle: ___________________ Maiden: ________________________ Spouse: ___________________________________________ Male Female Address: _______________________________________________ City: _______________________ State: _____ Zip: ________ Home Phone: _________________________ Work Phone: _________________________ Cell Phone: ______________________ E-Mail Address: ___________________________________________________ Date of Birth: _________________ Age: _______ Preferred form of communication? Cell Home Work E-Mail Social Security Number: ______ - ____ - _______ Current Employment (if any): ____________________________________________ Position: ____________________________ If retired, list name of previous employer & last position held: ______________________________________________________ Educational Background – High School: ___________________________________ College: ______________________________ Degree(s): __________________________________ Are you currently a student? Where? ______________________________ Please list a LOCAL emergency contact – Name: _______________________________ Relationship to you:__________________ E-Mail Address: ____________________________________________ Phone #:________________________________________ Scottish Rite Hospital offers a variety of different volunteer opportunities. Please choose which program works best for you. Dallas Campus: Frisco Campus: Day Program: Mon. Tues. Wed. Thurs. Fri. Day Program: Mon. Tues. Wed. Thurs. Fri. 8 a.m. to Noon Noon to 4 p.m. 8 a.m. to Noon Noon to 4 p.m. Evening Program: Mon. Tues. Wed. Thurs. Evening volunteering is 5:45 p.m. to 8:00 p.m. INTEREST: Have you volunteered with us previously? Yes, the Adult Volunteer Program Yes, the Junior Volunteer Program Yes, group/special event:__________________________________________ No, I have not volunteered previously How did you learn about our volunteer program? Website Volunteer Staff Friend/Family Patient/Parent Other _______________________________________ Who referred you? ________________________________________ Reason(s) for wanting to volunteer: ____________________________________________________________________________ Are you completing service hours as a requirement for another organization(s)? YES NO # of hours needed: __________ Organization(s) requesting hours? ______________________________________________________ Due Date: ______________ INTEREST (Continued): For Office Use Only: Additional Notes _________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Other current/previous volunteer experience (organization & # of years): ______________________________________________ _________________________________________________________________________________________________________ Organizational/Community activities: ___________________________________________________________________________ Skills/special interests: _______________________________________________________________________________________ Foreign Language Fluency? Spanish French Mandarin Other: ____________________________________ CRIMINAL BACKGROUND (Conviction will not necessarily disqualify volunteers): Have you been ever been convicted of any crime other than a minor traffic violation? YES NO If yes, please explain: _______________________________________________________________________________________ Have you ever been charged with child neglect, abuse or any crime involving a child? YES NO ADDITIONAL ATTACHMENTS & REQUIREMENTS Additional Attachments Incomplete applications will not be accepted. Please ask two individuals to complete the attached reference questionnaire. Your references need to be 18 years of age or older and have known you for at least two years (no relatives please). Questionnaires must be included with your application in a sealed envelope with the reference's signature across the seal. Proof of immunity or immunization • Volunteers born after 1956 must provide proof of immunity or immunization to ALL of the following: o MMR #1 & #2 (Measles or Rubeola, Mumps and Rubella)- 2 shots totaling 1mL o CHICKENPOX #1 & #2 – Proof of varicella vaccine (2 shots) or proof of disease from treating physician o TDAP (Tetanus, Diphtheria and Acellular Pertussis) – TDAP vaccinations must have been given within the last 10 years • Volunteers born in or before 1956 must provide proof of immunity or immunization to: o TDAP (Tetanus, Diphtheria and Acellular Pertussis) – TDAP vaccinations must have been given within the last 10 years Additional Requirements The following are required annually – further information will be provided by a volunteer coordinator. Tuberculosis screening. During Orientation, you will complete a TB screening. QFT's are administered at Scottish Rite, free of charge, or you may provide a recent copy (within 30 days) of a QFT Gold blood draw. Influenza Vaccination is required during Flu Season, November-April. You must provide record of immunization annually. Flu shots are administered at Scottish Rite, if available, or you may bring a copy with you. I understand that the information I have provided may be verified, if necessary, by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning me. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless Texas Scottish Rite Hospital for Children and its trustees, officers, employees and volunteers from liability for seeking or relying upon such information. Volunteer opportunities for qualified individuals are provided without regard to religion, creed, race, national origin, age, sex or disability status. I agree to adhere to the policies and procedures set forth by the Volunteer Program & Scottish Rite Hospital. I understand that failure to meet the volunteer program policies may result in my dismissal. Signature: __________________________________________________________ Date: ____________________ Mail: Volunteer Services Scottish Rite for Children 2222 Welborn Street, Dallas, TX 75219 In person at Monday – Thursday: 8 am to 6 pm Dallas Campus: Friday: 8 am to 4 pm Completed Applications: We do not accept applications by email or fax. 1. Confirmation Email will be sent to acknowledge receipt of application. 2. We will process your application, including a background check. Approximately 2-4 weeks. NEXT STEPS: 3. A Volunteer Coordinator will reach out to you regarding the status of your application. THANK YOU for applying! APPLICATION DISCLOSURE Background Check Consent for Volunteers Last Name: ____________________________________ First Name: ________________________________ Middle: ________________________________________ Maiden: __________________________________ Date of Birth*: ____________________ Social Security Number: ___________________________________ Current Address: __________________________________________________________________________ City: ________________________________ State: __________________________ Zip: ________________ Previous Addresses (Last 7 years): ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report** may be in connection with your application for volunteer placement and/or that periodic consumer reports may be made in connection with your continued volunteer position at Texas Scottish Rite Hospital for Children. If you are denied placement, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights. I have read the above notice and understand what it means. I hereby authorize the procurement of a consumer report for volunteer purposes. Signature: ________________________________________________________ Date: ______________ *for consumer report purposes only **A consumer report may consist of employment records, education verification, licensure verification, driving history, previous addresses, and other public records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are applying. Reference Questionnaire Adult Volunteer Application Thank you for agreeing to be a reference for _____________________________________! We would appreciate if you would answer the following questions, so that we can learn a little bit more about the volunteer applicant. Please seal the completed questionnaire in an envelope, sign the seal and return it to the applicant. Reference Name: ___________________________________________ Phone Number: __________________________ Email Address: ______________________________________________ How long have you known the applicant? _____ What is the nature of your relationship? ________________________________________________________________ Describe the applicant's reliability and willingness to make a commitment to volunteering. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you know of any problem the applicant has that would affect his/her volunteering with children/youth? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Would you recommend the applicant for placement in a setting such as ours? Yes No If not, do you feel he/she may be more suited for another type of volunteer agency? _____________________________ __________________________________________________________________________________________________ Would you entrust the care of your child to the applicant? Yes No – please explain: _____________________ __________________________________________________________________________________________________ Additional Comments: _______________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature: ______________________________________________________________ Date: _____________________ Reference Questionnaire Adult Volunteer Application Thank you for agreeing to be a reference for _____________________________________! We would appreciate if you would answer the following questions, so that we can learn a little bit more about the volunteer applicant. Please seal the completed questionnaire in an envelope, sign the seal and return it to the applicant. Reference Name: ___________________________________________ Phone Number: __________________________ Email Address: ______________________________________________ How long have you known the applicant? _____ What is the nature of your relationship? ________________________________________________________________ Describe the applicant's reliability and willingness to make a commitment to volunteering. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you know of any problem the applicant has that would affect his/her volunteering with children/youth? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Would you recommend the applicant for placement in a setting such as ours? Yes No If not, do you feel he/she may be more suited for another type of volunteer agency? _____________________________ __________________________________________________________________________________________________ Would you entrust the care of your child to the applicant? Yes No – please explain: _____________________ __________________________________________________________________________________________________ Additional Comments: _______________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature: ______________________________________________________________ Date: _____________________ ----Rxjc2T01;abELTH ----nw;rtwt;hxq ----AC;pwke;zsl I will be out of the office from Tuesday, February 18 through Friday, February 21. I will have access to email and will reply if necessary. All other emails will be returned on Monday, February 24. Thank you!
Services Manager
Recreation
573-874-7202
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Dear Prospective Ed.D., Higher Education Strand Applicant:
----XeDVgp6t;NcdBZV Dear Applicant, Thank you for your interest in KIU Academy. Here you will find a teacher application. Please complete and return/fax the enclosed application to be considered as an applicant. Our mission is to provide, from a Biblical perspective, a safe, nurturing environment where students can develop physically, mentally, emotionally, and spiritually, and an academically challenging environment where students can potentially become people of academic excellence. We are an accredited school by the Association of Christians Schools International (ACSI). If you find you have questions, please feel free to contact the school at employment@kyotoiu.ac.jp or phone us from outside Japan at +81-774-64-0804; from inside Japan at (0774)64-0804. Feel free to fax us your application papers to expedite matters. In Christ's name, Peter Blocksom President Kyoto International University/ KIU Academy Principal KIU Academy SCHOOL CONTACT INFORMATION Address: 1-1 Ichinotsubo Kusauchi Kyotanabe City Kyoto 610-0311 JAPAN Phone: +81-774-64-0804 Fax: +81-774-64-0805 E-mail: employment@kyotoiu.ac.jp Web: http://kiua.kyotoiu.ac.jp KIU ACADEMY Instructor's Application 2 KIU Academy Instructional Staff Application (K-12) PLEASE PRINT CLEARLY OR TYPE Date: PERSONAL INFORMATION: Name: Date of Birth: (Last) (First) (MI) (Nickname) Mailing Address: Country: Home Phone: Business Phone: Email Address: Desired Position(s): Elementary School Middle School High School Willing to work: (Please check all that apply) Full time Part time Substitute Date available for employment: How did you learn about this job opportunity? Marital Status: Married Single Widowed Divorced Briefly explain: Gender: Male Female Children: Name: Age: Name: Age: Name: Age: Name: Age: TEACHER CERTIFICATE: None Valid Specify Country/State: Expires: License #: Certification Area(s) EDUCATION/TRAINING Name and location of Schools attended Course of study and Major/Minor Diploma, degree, Certificate, or license held Year Graduated (College only)
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