First Name

Last Name

Email Address

Phone

Address

City

State

Zip

Volunteer Opportunities Volunteer Opportunities Which Volunteer opportunities are you interested in? (Check all that apply) **Criminal Background Check Required for these tasks Hotline Advocate On-Call Advocate Children's Services Peer Mentoring Internship Office Advocate Special Projects Transportation Public Education Resale Store (Flamingos)

Volunteer Availability Volunteer Availability When can you volunteer? Weekdays Evenings Weekends Varies

Language Proficiency Language Proficiency Are you bilingual? Yes No

Language(s)

Employment Status Employment Status Employed Student Retired Not Employed Interested in employment at ETCC

Employer

May we contact you at work? May we contact you at work? Yes No

What is the best way to contact you during business hours? What is the best way to contact you during business hours? *Phone CallText MessageEmail

Emergency Contact

Emergency Contact Phone

What personal strengths do you believe you will bring to this agency:

List any college, university or technical training:

Have you ever been convicted for a law violation (other than a routine traffic violation) or are you currently on deferred adjudication or probation? Have you ever been convicted for a law violation (other than a routine traffic violation) or are you currently on deferred adjudication or probation? Yes No

If yes, please list offense and when it occurred:

Name Please list two references from non-relatives and one from member of your family (other than your spouse)

Relationship

Daytime Phone

Email

Address, City, State, Zip

Name

Relationship

Daytime Phone

Email

Address, City, State, Zip

Name

Relationship

Daytime Phone

Email

Address, City, State, Zip

Spouse's Name

Child's Name

Child's Age

Child's Name

Child's Age

Child's Name

Child's Age

Child's Name

Child's Age

Photography Consent Photography Consent Occasionally, the East Texas Crisis Center photographs or videotapes volunteers and staff at work in a variety of situations. Images are generally used for:  Display panels used for exhibits at public events or conferences.  Brochures, fact sheets, program materials, reports, calendars, newsletters, etc.  Web page on the internet. Please indicate whether you give permission to the East Texas Crisis Center to use your picture in our public and intra-agency media. Yes, picture and name Yes, picture only No, please DO NOT use my picture at all

Date of Birth (mm/dd/yyyy)

SS# (xxx-xx-xxxx)

Driver's License #

Issuing State

Signature Signature I, hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Enter your name as your signature

First Name

Last Name

Date

Code of Confidentiality & Ethics Code of Confidentiality & Ethics The East Texas Crisis Center adheres to the highest possible standards of ethical conduct regarding clients, co-workers, board members, students, and volunteers. The East Texas Crisis Center is dedicated to the self-growth, support, and empowerment of all clients. The professional relationship between East Texas Crisis Center staff and clients will aim for the highest moral and ethical values possible. Staff includes employees, board members, volunteers, interns, and practicum students. Responsibility to Clients 1. Staff providing direct client services shall maintain the client’s interest as their primary responsibility. 2. Staff should respect the privacy of clients and maintain confidentiality at all times regarding information obtained while providing services, except as otherwise required by law or judicial order. 3. Personal client information should not be disclosed without written consent of the client or client’s legal representative, except in those circumstances in which not to do so would result in clear danger to the client or to others. 4. Client confidentiality must be maintained throughout the work place. Client information will not be discussed in the front office or in the hallways of any Counseling Center. Resident information will not be discussed in the resident’s general living area or administrative hallways. 5. When Counseling Center Staff provide information to co-workers or supervisors, they have a responsibility to ensure that the content is general. Whenever possible, client cases should be staffed without identifying clients by name. 6. Staff should follow the East Texas Crisis Center policy to maintain confidentiality in the storage and disposal of client files and information. 7. When Staff receive supervision or seek consultation outside the East Texas Crisis Center, client information should only be discussed for professional purpose and only with persons clearly concerned with the case. In an effort to avoid undue invasion of privacy, clients should not be identified by name. 8. Staff who present personal client information during the course of professional work in writings, lectures, public forums, or training sessions must obtain adequate prior consent to do so or adequately disguise all identifying information. 9. Staff should make every effort to foster personal growth and empowerment with each client. 10. Staff will give the client a clear description of services, reports, and fees. 11. Staff will avoid dual relationships with clients. Staff will not conduct any relationship with the client other than as professional service provider or violate the position of trust in any manner be detrimental to the client. 12. Staff may not discriminate against clients on the basis of sex, age, race, creed, color, national origin, religion, marital status, disability, sexual orientation, political affiliation, or source of income. 13. Information regarding a client’s violation of the East Texas Crisis Center policies or rules may not be used by Staff against that client when the client is working toward improvement, and action on the part of the East Texas Crisis Center would be detrimental toward the client’s continued improvement. Page 2 Confidentiality and Code of Ethical Conduct 14. All Staff involved in direct service to a client will contribute to the decision making process on decisions which affect the type of service provided, length of service, or termination of service. 15. Staff recognize their boundaries of competence and provide only those services, and use only those techniques, for which they are qualified by training or experience. 16. If a client is already in a counseling relationship with another professional person, the staff does not enter into a counseling relationship without first contacting and receiving the approval of that other professional. 17. Staff should screen prospective group participants, especially when the emphasis is on self-understanding and growth through self-disclosure. Staff must maintain an awareness of the group participants’ compatibility with other group members and preserve the integrity of the purpose and goals of the group. 18. When the Staff is engaged in short-term group treatment training programs (i.e., marathons, and other growth groups), Staff ensures that there is professional assistance available during and following the group experience. 19. Confidentiality must be maintained after the employee, volunteer, board member, intern, practicum student, resident, and nonresident leaves the East Texas Crisis Center. 20. The executive director or, in the executive director’s absence, a designated staff must be notified immediately if a court order is served to a current or former employee, volunteer, board member, intern, or practicum student, regarding any program, residents, nonresidents, shelter center activities, or personnel issues. Responsibility to Co-workers 1. Staff will treat co-workers with respect, fairness and courtesy, and shall operate in a regard to clients on principles of good faith. 2. Staff will treat clients of a co-worker with the same respect and professional courtesies which would be extended to their own clients. 3. Staff may not become involved in a dual relationship with a co-worker whom he or she supervises or is supervised by, or any member of the Board of Directors. 4. Staff will not condone or engage in sexual harassment which is defined as deliberate or repeated comments, gestures, or physical contacts of a sexual nature. I have read the Code of Confidentiality & Ethics and by Checking this box I Agree & Commit to uphold the principles of Confidentiality & Ethical conduct.

Date

First Name

Last Name

Maiden Name (or other names used)

Date of Birth (mm/dd/yyyy)

SS# (xxx-xx-xxxx)

Driver's License #

Length of Residency in Texas

Sex (Female or Male)

Signature Signature I hereby authorize the East Texas Crisis Center to obtain any information from employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, performance, attendance, personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use by the East Texas Crisis Center and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities. I, hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Enter your name as your signature

First Name

Last Name

Date