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Volunteer Form

Instructions for Completing the Background Check Authorization form, DSHS 09-653

Prior to any appointment of volunteer activities at Tierra Village, candidates must submit a completed application, undergo an interview, complete necessary forms and allow the time needed for Tierra staff to process the application and background checks. We thank you for your interest in working with our residents and participants.

Personal Information

Contact Information
Availability
During which hours are you available for volunteer assignments?
Certificates
Do you have any of the following (check all that apply, and list date obtained)
Interests
Tell us in which areas you are interested in volunteering.
Special Skills or Qualifications
Previous Volunteer Experience
Agreement and Signature
Sign above

Our Policy

Tierra Village is an equal opportunity employer. No employees and/or volunteer or applicant for employment shall be unlawfully denied an employment opportunity because of race, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, place of birth, age, veteran status, disability, pregnancy, genetic information, or other category protected by law. Tierra Village is committed to non-discrimination in its employment. Thank you for completing this application form and for your interest in volunteering with us.

Other Information

Section 1. Required: Applicant Information (All sections completed by the applicant, the person receiving a background check). The requesting entity w ill submit the applicant’s information through the online Background Check System (BCS).
OTHER ALIAS FIRST, MIDDLE, AND LAST NAMES YOU HAVE USED
Other Information
I authorize BCCU to leave a detailed message.
Have you lived in any state or country other than washington state within the last three years (36 Months)?
Mailing address where we can send you confidential information
Physical address where you live now (write “same” if address is the same as your mailing address)
Section 2. Required: Self-Disclosure Questions for ALL convictions and pending charges from any state or jurisdiction. You must answer Questions 11A through 14.
Have you been convicted of any crime?
Do you have charges (pending) against you for any crime?
Has a court or state agency ever issued you an order or other final notification stating that you have sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult?
Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government agency w as taking action against you for failing to care for children, juveniles, or vulnerable adults?
Has a court ever entered any of the follow ing orders against you for abuse, sexual abuse, neglect, abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile, or child?

• Permanent vulnerable adult protection order / restraining order, either active or expired, under RCW 74.34.
• Sexual assault protection order under RCW 7.90.
• Permanent civil anti-harassment protection order, either active or expired, under RCW 10.14.
I am the person named above. If I do not tell the w hole truth on this form, I understand I can be charged w ith perjury and I may not be allow ed to w ork w ith vulnerable adults, juveniles, or children. I understand and agree my signature in the box below means:

List of Crimes and Pending Charges

Print your name as it is listed on your driver’s license or government issued photo id
Section 3. Question 11A. If you check YES, you must enter the crime name, degree (if any), state, conviction date, and crime information.
1
Other crime information:
2
Other crime information:
3
Other crime information:
Section 4. Question 11B. If you check YES, you must enter the PENDING charge name, degree (if any), state, and crime information.
Other crime information:
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