The process of becoming a volunteer within the Florida Department of Corrections is facilitated through the submission of the DC5-601A Volunteer Application form, a comprehensive document designed to gather personal information, security clearance details, and other pertinent data from potential volunteers. This form requires applicants to provide their name, address, contact information, and volunteer group name, in addition to specific identity verification details such as Social Security numbers, driver’s license information, and personal characteristics like hair and eye color, height, and weight. Crucially, it delves into the applicant's criminal history, asking about past arrests or convictions, existing relationships with incarcerated individuals, and prior employment or relations within the Department. The form underscores the importance of honesty and accuracy in the submission process, highlighting that intentional falsification of information can lead to the disapproval of the volunteer application. It also covers the commitment to abide by departmental rules, cooperate with staff, maintain confidentiality of medical information, and adhere to a drug-free workplace policy, alongside the agreement to waive liability for injuries incurred during service. Completion of the application is followed by an acknowledgment that all information provided is correct and that the applicant agrees to the conditions set forth, including a waiver of liability and commitment to policy adherence. This form not only serves as a gateway for individuals aiming to contribute their time and skills to the correctional system but also acts as a critical tool for maintaining the safety and integrity of the department and its volunteers.
| Question | Answer |
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| Form Name | Form Dc5 601A |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | oci, department of corrections forms, florida rebate form, pli |
FLORIDA DEPARTMENT OF CORRECTIONS
VOLUNTEER APPLICATION
Pers o na l I nfo r matio n
Na me: Addr es s :
L a s t |
F i r s t |
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M i d d l e |
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M a i d e n |
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C i t y |
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S t a t e |
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Z I P C o d e |
T e l e p h o n e # 1 |
T e l e p h o n e # 2 |
E - M a i l A d d r e s s |
Volu nt eer Gr ou p Na me:
S ecurity C lear a nce I nfo r ma tio n
S ocia l S ecu r it y # :
Ra ce/ E t hnic Or igi n:
Dr iver s L icens e # :
Ha ir C olor :
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Dat e of Bir t h: |
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Gen d er : |
Ma le |
F ema l e |
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DL S tat e: |
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E ye C ol or : |
Hei g ht : |
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1 . Ha ve you ev er b een arr es t ed o n a mis d eme a nor or felon y cha r ge? If yes , ex p la in . (Us e a ddit io na l pa p er if nec es s a r y)
Yes
No
2 . Ha ve you ev er b een co nv ict ed o n a mis d em ea n or or felon y cha r ge? If yes , ex p la in . (Us e a ddit io na l pa p er if nec es s a r y)
Yes
No
3 . Do you ha ve a r ela t ions h ip (for exa mp l e p ar ent , s p ou s e, fr iend, et c) or ar e you curr ent ly on t he
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vis it at ion lis t of a nyo n e i nca r cera t ed? |
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If yes , giv e t he inmate’s na me, DC #, a nd y ou r r ela t ions hip t o t he in ma t e. |
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Na me: |
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DC # : |
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R ela t ions hip : |
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Ha ve you ev er wor k ed for t he F lor ida Depar t ment of C orr ect io ns ? |
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If yes , p lea s e indi ca t e wh er e a nd wh en y ou wer e emp l oy ed. |
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5 . |
Do you ha ve a ny r ela t ives wor ki n g for t he Dep a rt ment of C orr ect ions ? |
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If yes , pr ovid e: Na me: |
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R ela t ions hip : |
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Wor k L oca t ion: |
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I n cas e o f e merg e ncy no ti fy : |
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Na m e |
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(ar ea cod e + n um ber ) |
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D C 5 - 60 1 A ( Re vi s ed 10/ 22/ 15 )
In a ccor d an ce wi t h s . 11 9 . 07 1( 5) ( a) 2, you r s oci al s e cur i t y nu m ber i s b ei n g col l e ct ed i n or d er t o com pl et e an
F C IC / N C IC s e cur i t y r ep or t s o t hat you ca n be ap pr oved as a vol unt eer . T he D epa r t me nt wi l l n ot u s e t he s oci al
s e cur i t y n u mb er col l e ct ed f or an y p ur p os e ot he r t h an t h e pur p os e pr ovi d ed ab ove . Qu al i f i ed ap pl i ca nt s ar e con s i de r e d w i t h out d i s cr i mi n at i on bas ed up on r a ce, col or , nat i on al or i gi n, a ge r el i gi ous pr e f er e n ce, or h an di cap . Int ent i on a l l y
f a l s i f yi n g or om i t t i n g i n f or mat i on ma y r e s ul t i n di s app r oval of you r vol unt eer ap pl i cat i on .
IN CONSIDERATION OF THE OPPORTUNITY TO SERVE IN THE DEPARTMENT OF CORRECTIONS AS A CITIZEN VOLUNTEER:
∙I a cknowl edg e t ha t t oda y I ha ve b een fu r nis hed wit h a cop y of t he volu nt eer ru les ,
∙I ha ve r ea d, u nder s t ood a nd s ig n ed a n Ack no wl ed g ement of R es p ons ib il it y t o Ma int a in
C onfi d ent ia lit y of M ed ica l Infor ma t io n, DC 2
∙I u nder s t a nd t ha t I a m r es p ons ib l e for r ea din g a nd co mp ly i ng wit h t he r u les .
∙I wil l wor k in co op er at ion wit h s ta ff.
∙I wil l ho nor t he civ il a nd l ega l r ight s of a ll offend er s / in ma t es .
∙I wil l not u s e my off icia l p os it io n t o s ecu r e priv il eg es or a dva nta ges for mys elf .
∙I wil l r ep or t u net h ica l b eha vi or or r u le vio la t ions t o a n ap pr opr iat e Dep ar t ment s up er vis or .
∙ I will n ot dis cr imi na t e a ga ins t a ny offend er / in ma t e, emp l oy ee, or pr os p ect iv e emp lo y ee on t he b a s is of ra ce, gen d er , cr eed, na t iona l or igi n, or r eli gi ou s pr efer enc e.
∙I a ckno wl ed g e t he dr u g - fr ee wor kp la ce p olic y of t he Dep art ment of C orr ect io ns a nd I kno w I a m s u b ject t o ra ndo m dr u g t es t ing.
∙ I a gr ee t o a b ide b y |
t he |
p o lic i es a nd p r ocedu r es r eg ar din g |
co nfi d ent ia lit y |
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r ec or ds |
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med ica l infor ma t ion. |
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W A I VE R O F LI A BI LIT Y |
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I her eb y wa iv e a ll lia b ilit y |
t o |
t he Dep a rt ment of C orr ect ions a nd |
it s emp l oy ees , |
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a ny a nd |
a ll |
in ju r ies whic h ma y occu r t o me du r ing my t er m of s er vic e wit h t he Dep a rt ment of C orr ect ions .
Volunteers and interns, when working for the department, are covered by Worker’s Compensation in a ccor da nce wit h C ha pt er 44 0 of t he F lor ida S ta tu t es . I u nd er s ta nd t ha t I a m t he p er s on r es p ons ib l e t o
ens u r e t hat I a m in co mp lia nc e |
wit h a n y a nd a ll a pp lica b le S ta t e La w, Dep art ment of C or r ect ions |
P olic y, or a ny R egu la t ion whic h |
ma y a ffect me du r ing t his p er io d. |
I confirm that all the information on the application is correct and have read the Acknowledgement of Responsibilities, Waiver of Liability, and agree to abide by the conditions therein.
S ig nat ure: |
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D ate: |
Fo r T ho s e Co mp let i ng R eg ul ar V o lunte er Trai ni ng :
Pers o n C o nd ucti ng V o l unteer T rai ni ng :
L o catio n:
O ffici a l U s e:
F. A . S . T . Pi n # : |
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FC I C / N C I C 1 |
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T rai ni ng D ate: |
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D ate: |
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H its : |
Y es |
N o |
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A ppro v ed: |
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D ate: |
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(A ppro v ing A ut ho r ity 2) |
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Signature of Volunteer |
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Date: |
Volunteer’s Printed Name: |
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1An annual background check should be done for each active regular service volunteer. The temporary volunteer badge is produced in accordance with “Identification Cards,” Procedure 602.056.
2The Chaplaincy Services Administrator or institutional lead Chaplain is the approving authority when the volunteer has no previous period of incarceration or supervision. When a proposed volunteer has a previous period of incarceration or supervision, the approving authorityis the Assistant Secretary for institutions or designee. (“Volunteers,”
Procedure 503.004).
D C 5 - 60 1 A ( Re vi s ed 10/ 22/ 15 )
In a ccor d an ce wi t h s . 11 9 . 07 1( 5) ( a) 2, you r s oci al s e cur i t y nu m ber i s b ei n g col l e ct ed i n or d er t o com pl et e an
F C IC / N C IC s e cur i t y r ep or t s o t hat you ca n be ap pr oved as a vol unt eer . T he D epa r t me nt wi l l n ot u s e t he s oci al
s e cur i t y n u mb er col l e ct ed f or an y p ur p os e ot he r t h an t h e pur p os e pr ovi d ed ab ove . Qu al i f i ed ap pl i ca nt s ar e con s i de r e d w i t h out d i s cr i mi n at i on bas ed up on r a ce, col or , nat i on al or i gi n, a ge r el i gi ous pr e f er e n ce, or h an di cap . Int ent i on a l l y
f a l s i f yi n g or om i t t i n g i n f or mat i on ma y r e s ul t i n di s app r oval of you r vol unt eer ap pl i cat i on .