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Volunteer Application

Step 1 of 5

20%

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Email

Date of Birth

Desired Volunteer Job & Location

Emergency Contact

First Last

Emergency Contact Phone

Are you 18 years old or older?(Required)

Yes

No

Have you ever been convicted of a felony?(Required)

No

Yes

Please Explain:(Required)

Address on Driver's License(Required)

Street Address Address Line 2 City State ZIP Code

Previous Address (if not Indiana resident for past six (6) months)s

Street Address Address Line 2 City State ZIP Code

References

Reference #1(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Relationship(Required)

Reference #2(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Relationship(Required)

Photo Release(Required)

By checking the box below, you acknowledge that you have read and agree to the statement:

I agree to release without limitation, all claims to photographs, video images, audio recordings or information about me in regard to my volunteer experience. I agree these may be reproduced for use by LifeStream Services Inc. for print and online promotions, videos, reports, printed materials, and other publicity as warranted by LifeStream Services Inc. I also agree all claims for compensation or damages are hereby waived.

Confidentiality & Non-Disclosure Agreement:(Required)

By checking each box, you acknowledge that you have read each statement and agree to these statements:

Nondisclosure. I hereby acknowledge and agree the confidentiality of all personal information to which I gain access is protected by state and federal law. I further acknowledge and agree that I will not use or disclose any personal information at any time or for any reason whatsoever in a manner which violates any state or federal law, including without limitation, the Privacy Rules.

I acknowledge and agree any violation of this agreement may result in LifeStream Services Inc. imposing immediate termination of contract.

General. This agreement may not be amended except in writing and signed by both parties hereto. No failure or delay in exercising any right, power or remedy hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any other right, power or remedy. This agreement constitutes the entire agreement between the parties hereto relating to the subject matter hereof, and supersedes any prior or contemporaneous verbal or written agreements, communications and representations relating to the subject matter hereof.

Voluntary Participation & Execution:(Required)

By checking the box below, you acknowledge that you have read and agree to the statement:

I acknowledge and willing agree to serve as a volunteer for LifeStream Services Inc. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and LifeStream Services Inc. I sign it of my own free will.

Please initial here (this will be used as your signature)(Required)

Background Check Authorization

Background Check Authorization(Required)

By checking each box, you acknowledge that you have read each statement and agree to these statements:

I hereby authorize LifeStream Services, Inc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment processes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to LifeStream Services, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I further authorize LifeStream Services, Inc. to do an annual and/or random background checks for the purpose of evaluating my continued employment.

I understand pursuant to the federal Fair Credit Reporting Act, LifeStream Services, Inc. will provide me a copy of any such report if the information contained in it is, in any way, to be used in making a decision regarding my employment and/or continued employment with LifeStream Services, Inc. I further understand that such report will be made available to me prior to any such decision being made.

I hereby release LifeStream Services, Inc., and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Please initial here (this will be used as your signature)(Required)

Request for Reference

Reference Authorization(Required)

I authorize LifeStream Services, Inc. to contact my current and any former employers and references in order to investigate my past performance and other information contained on my application. I further authorize my current and former employers to respond to the questions set forth by LifeStream Services, Inc. and its designated representatives.

By checking the box below, you acknowledge that you have read and agree to the statement:

Please initial here (this will be used as your signature)(Required)

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