Red Cross Volunteer Application Form – Fill Out and Use This PDF

Eastern OK Region	SW Region Blood Services	Bartlesville Community Chapter	SE Oklahoma Community Chapter
Volunteer Services	Volunteer Services	Volunteer Services	Volunteer Services
LINDSEY JENSEN	CONNIE SHERRIFF	CHUCK KERNS	RENE BEEZLEY
10151 East 11th Street	10151 East 11th Street	601 SW Jennings Street	502 East Chickasaw Avenue
Tulsa, OK 74128	Tulsa, OK 74128	Bartlesville, OK 74003	McAlester, OK 74501
(918) 831-1226	(918) 831-1868	(918) 336-2216	(918) 423-0481
FAX: (918) 831-1193	FAX: (918) 831-1288	FAX: (918) 336-2218	FAX: (918) 423-1864
lindsey.jensen2@redcross.org	connie.sherriff@redcross.org	ckerns@okredcross.org	rbeezley@okredcross.org
www.okredcross.org	www.redcrossblood.org	www.okredcross.org	www.okredcross.org

AMERICAN RED CROSS VOLUNTEER APPLICATION

Date

Age Group  14-17  18-24

If Youth, indicate name of school:

 25-40  41-54  55+

Last Name

First Name

Middle Name

Nick Name

Date of Birth

Title

 Mr.  Mrs.

Suffix

 R.N. 

L.P.N.  M.D.  L.P.C.

 Ms.  Dr.

Gender (circle one)

M F

 Other________

 Other_____________

Home Address

Apt #

City

State

Zip Code

Work Address

Suite

City

State

Zip Code

Home Phone

Work Phone

Cell Number

E-Mail Address

Employer

Occupation

Emergency Contact

Name

Phone

Relationship

Experience (Include both paid and volunteer work experience, beginning with most recent)

Business | Organization Name

Address

Phone

From

To

Supervisor’s Name/Title

Business | Organization Name

Address

Phone

From

To

Supervisor’s Name/Title

Current License(s) (Include both professional and driver’s license)

Type

Number

State

Expiration Date

Type

Number

State

Expiration Date

Education (Highest level achieved)

	Institution Name	City/State			Degree/Major	Dates Attended
	Fluent Language Skills (Include sign language)
	Skills & Personal Interests
	 Building Trades	 Driving (long/short distances)  Journalism				 Public Speaking
	 Communications	 Events Coordination			 Management	 Teaching
	 Computer Support	 Office Support			 Photography	Graphic Design
	 Fund Raising	 Reception			 Public Relations	 Other (describe below)

Description:

Availability

 AM (8:00 AM-12:00 PM)  PM (12:00 PM-5:00 PM) After 5:00 PM

(Please note that some volunteer areas are available only during the workday M-F. This is discussed at the volunteer interview.)

	 Sunday	 Monday	 Tuesday  Wednesday  Thursday		 Friday		 Saturday
	Volunteer Position Please indicate the area(s) you are interested in:
	Chapter Volunteer Services:						Blood Volunteer Services:
	 Disaster Response		 Youth & Community Education Programs				 Blood Donor Registration
	 CPR/First Aid Instructor (Tulsa only)  Clerical/Data Entry/Front Desk						 Blood Product Driver
	 General Services (building trades; fleet conservation) (Tulsa only)						 Blood Donor Canteen
	 Services to Armed Forces  Ready When the Time Comes (groups only)						 Unsure (discuss during interview)
	 Mental Health Services		 Disaster Health Services

 Unsure (discuss during volunteer interview)

Previous Red Cross Experience

Have you ever worked as a Red Cross volunteer? (If yes, give volunteer role, dates, and location.)

Have you ever worked as a Red Cross employee? (If yes, give position, dates, and location.)

Have you ever held any Red Cross certifications (CPR/First Aid, Disaster Classes, etc.)? (If yes, please list.)

References (List two non-relatives that we may contact to verify the information provided on this application).

Name	Address	Phone	Relationship
Name	Address	Phone	Relationship
How did you hear about volunteering for the American Red Cross?
Why do you wish to volunteer with the American Red Cross?

A “yes” answer to the following italicized questions does not necessarily disqualify an applicant:

Are you licensed to operate a motor vehicle in this state?

Has your license to operate a motor vehicle ever been revoked? If yes, please explain.

Have you ever been convicted of a felony or misdemeanor within the past 7 years? If yes, please explain. (A mandatory background check will be completed at the volunteer interview.)

Have any of your Red Cross certifications ever been revoked? If yes, please explain.

I hereby give the Tulsa Area Chapter of the American Red Cross permission to inquire into my references, driving records and volunteer history. I further understand that a criminal background check will be conducted. I give permission to the holder of any such records to release the same to the Tulsa Area Chapter of the American Red Cross.

I hereby hold the American Red Cross harmless from any liability, whether civil or criminal, that may arise as a result of the release of this information. I further hold harmless any individual, agency, business or corporation that provides information or documents to the above named American Red Cross unit. I understand that the Tulsa Area Chapter will use this information as part of its verification of my volunteer application and periodically for evaluation purposes.

I understand that the above information is voluntarily supplied and may be used and disclosed for Red Cross purposes only. I further acknowledge that my name and personal information will not be sold for mailing list purposes.

Signed:

_____________________________________

Date:

_________________

STATISTICAL INFORMATION

The Tulsa Area Chapter, in recognition of its responsibility to its paid and volunteer staff and the community it serves, reaffirms its policy to assure fair and equal treatment in all of its employment practices, for all persons. We will not discriminate on the basis of race, color, religion, sex, age or national origin, not against any qualified handicapped individual. The following information is requested solely to determine diversity of the Red Cross volunteers. Completion is optional; however, it would be most helpful to us as we monitor our volunteer program.

GENDER: Male_____Female_____ DATE OF BIRTH: _______/_______/_______

DO YOU CONSIDER YOURSELF TO BE (FILL ONLY ONE):

_______White or Caucasian _______Black or African American					_______Hispanic or Latino
_______Asian _______Native Hawaiian or Other Pacific Islander					_______Eastern Indian
______American Indian/Alaska Native	______Other (please indicate) ___________________
WHAT IS THE HIGHEST LEVEL OF EDUCATION THAT YOU HAVE COMPLETED?
_______Less than High School
_______High School graduate or equivalent
_______Some college or technical training beyond High School
_______College graduate
_______Post-graduate or professional degree
DO YOU CONSIDER YOURSELF TO BE (Check all that apply)
_______ Physically Handicapped	_______ Mentally Handicapped
_______ Retired	_______ Unemployed and looking for work
HOUSEHOLD INCOME:
_______ Household income less than $38,000
_______ Household income between $38,000 and $63,000
_______ Household income more than $63,000
Number of individuals in household (please circle) 1		2	3	4	5	6+

PARENTAL CONSENT

RELEASE AND WAIVER OF LIABILITY

I authorize and give permission for my child, ______________________, to serve as a youth volunteer and to participate in Red Cross

activities and events under the supervision of an American Red Cross staff member. I, the parent/guardian of the above-named minor, for myself and behalf of my child:

1.Acknowledge that my child’s participation may involve risk of injury, including economic losses, which may result from my child’s own actions, inactions, or negligence; from the actions, inactions, or negligence of others; from the conditions of the facility; or from the equipment or areas where the event is being conducted.

2.Release, waive, discharge, and relinquish the American Red Cross and the Tulsa Area Chapter, their officers, directors,

employees, and agents, from any and all liability, loss, damage, claim, demand, or cause of action against them, arising out of or related to my child’s participation in Red Cross activities as a youth volunteer.

3.Assume all risks of bodily injuries to my child and give permission for my child to be taken to a hospital and/or treated by licensed medical staff for medical emergencies of illness and/or injuries, and for licensed medical staff to take emergency measures as they deem appropriate.

4.Agree that photographs, pictures, slides, movies, or videos of my child may be taken in connection with his or her participation in Red Cross events or activities. I understand that participation offers no remuneration, and consent to the use of photographs, pictures, slides, or videos for any legal purpose.

I have read this document, I understand that it has significant legal consequences, and I sign it voluntarily.

DATE: _____/_____/_____

SIGNATURE: _____________________________________

Relation to minor: ___________________________________

HOME PHONE: ____________________ WORK PHONE:___________________

EMERGENCYCONTACT: ________________________________________________________

HOME PHONE: ______________________ WORK PHONE: _______________________

AMERICAN RED CROSS CODE OF BUSINESS ETHICS AND CONDUCT

The American Red Cross is a not-for-profit charitable organization dedicated to providing services to those in need. The Red Cross has traditionally demanded and received the highest ethical performance from its employees and volunteers. In an effort to maintain the high standard of conduct expected and deserved by the American public and to enable the organization to continue to offer its services, the American Red Cross operates under the Code of Business Ethics and Conduct outlined below. All employees and volunteers are required to sign the Code of Business Ethics and Conduct form certifying that, in delivering Red Cross services and in all other Red Cross activities, they shall meet the following standards of conduct:

Compliance Requirements. All employees and volunteers are required to comply with applicable federal, state and local laws and regulations and with American Red Cross corporate policies and regulations.

Actions Prohibited by the Code of Business Ethics and Conduct. No employee or volunteer shall engage in the following actions:

a.Personal Use. Authorize the use of or use for the benefit or advantage of any person, the name, emblem, endorsement, services or property of the American Red Cross, except in conformance with American Red Cross policy.

b.Financial Advantage. Accept or seek on behalf of or any other person, any financial advantage or gain of other than nominal value offered as a result of the employee’s or volunteer’s affiliation with the American Red Cross.

c.Red Cross Affiliation. Publicly use any American Red Cross affiliation in connection with the promotion of partisan politics, religious matters or positions on any issue not in conformity with the official position of the American Red Cross.

d.Confidentiality. Disclose any confidential American Red Cross information that is available solely as a result of the employee’s or volunteer's affiliation with the American Red Cross to any person not

authorized to receive such information, or use to the disadvantage of the American Red Cross any such confidential information, without the express authorization of the American Red Cross.

e.Improper Influence. Knowingly take any action or make any statement intended to influence the conduct of the American Red Cross in such a way as to confer any financial benefit on any person, corporation or entity in which the individual has a significant interest or affiliation.

f.Conflict of Interest. Operate or act in a manner that creates a conflict or appears to create a conflict with the interests of the American Red Cross and any organization in which the individual has a personal, business or financial interest. In

the event there is a conflict, the American Red Cross has a structured conflict of interest process. First, the individual shall disclose such conflict of interest to the chairman of the board or the chief executive officer of the individual’s Red

Cross unit or the general counsel of the American Red Cross, as applicable. Next, a decision will be made about the conflict of interest, and, where required, the individual may be required to excuse or absent himself or herself during deliberations, decisions and/or voting in connection with the matter.

g.Retaliation . Retaliate against any employee or volunteer who seeks advice from, raises a concern with or makes a complaint to a supervisor or other member of management, the ombudsman, the Concern Connection Line, the Biomedical Regulatory Hotline or any other whistleblower program, about fraud, waste, abuse, policy violations, discrimination, illegal conduct, unethical conduct, unsafe conduct or any other misconduct by the organization, its employees or volunteers.

h.Contrary to the Best Interest of the Red Cross. Operate or act in any manner that is contrary to the best interest of the American Red Cross.

Ombudsman Program – Informal Dispute Resolution. The American Red Cross has an organizational ombudsman designated as the neutral or impartial dispute resolution practitioner whose major function is to provide confidential and

informal assistance to the many constituents with concerns or complaints about the Red Cross. The constituents who seek the ombudsman’s services are internal stakeholders, such as employees and volunteers, and external stakeholders, such as Red

Cross clients, donors, suppliers, vendors and the public at large. The ombudsman provides a voluntary, confidential and informal process to facilitate fair and equitable resolutions and explore a range of alternatives or options to resolve the problems. If a formal investigation is what the individual seeks, referrals to the whistleblower hotlines may be appropriate.

Investigations, Compliance and Ethics – Formal Dispute Resolution. Distinguishing from the actions of the ombudsman, the Office of the General Counsel and the Office of Investigations, Compliance and Ethics (IC&E) conduct formal investigations into allegations of fraud, waste, abuse, Red Cross policy violations, illegal or unethical conduct or other improprieties regarding the Red Cross. Usually, the allegations arise from whistleblower complaints of Red Cross employees and volunteers seeking formal review or investigations of their allegations of wrongdoing.

Whistleblower Hotline Programs. The American Red Cross encourages open communications. All employees and volunteers are encouraged to bring any concerns they have regarding the organization or its employees and volunteers to their direct supervisor. If individuals seek an informal and confidential resolution, the ombudsman may be the appropriate choice. If a formal IC&E investigation is sought, the hotlines described below are the appropriate choice.

If an employee or volunteer suspects or knows about misappropriation, fraud, waste, abuse, Red Cross policy violations, illegal or unethical conduct, unsafe conduct or any other misconduct by the organization or its employees or volunteers, that individual should alert his or her supervisor or other member of local management. In those cases where an employee or volunteer is not comfortable telling his or her supervisor or local management, the employee or volunteer may contact the Concern Connection Line at 1-888-309-9679. For concerns about the collection, manufacturing, processing, distribution or utilization of blood or blood components (e.g., violations of FDA or OSHA regulations, falsification, quality failures, training, Biomedical Services computer and equipment issues), an employee or volunteer who is not comfortable with contacting his or her supervisor or local management may contact the Biomedical Regulatory Hotline at 1-800-741-4738.

CERTIFICATION OF COMMITMENT TO THE CODE OF BUSINESS ETHICS AND CONDUCT

I, ______________________________________________, certify that I have read and understand the Code of Business Ethics and

Conduct of the American Red Cross and agree to comply with it, as well as applicable laws that impact the organization, at all times. I affirm that, except as listed below, I have no personal, business or financial interest that conflicts, or appears to conflict, with the best interests of the American Red Cross. I agree to discuss any conflicts listed below with the chairman of the board or the chief executive officer of my unit or the general counsel of the American Red Cross and to refrain from participating in any discussions, deliberations, decisions and/or voting related to the matter presenting the conflict until such time as it is determined by the Red Cross that the conflict is mitigated or otherwise resolved.

Describe any potential conflicts:

______________________________________________________________________________

_________________________________________________________________________________

At any time during the term of my affiliation with the American Red Cross, should an actual or potential conflict of interest arise between my personal, business or financial interests and the interests of the Red Cross, I agree to: (1) disclose promptly the actual or potential conflict to the chairman of the board or the chief executive officer of my Red Cross unit or the general counsel of the American Red Cross; and (2) until the Red Cross approves actions to mitigate

or otherwise resolve the conflict, refrain from participating in any discussions, deliberations, decisions and/or voting related to the conflict of interest.

Signature:	____________________________________________		Date:	_______________________
Print Name:		__________________________________________
Rev. January 2007

American Red Cross

Policies Acknowledgement

All policies listed below are stated in the Volunteer Handbook. The Volunteer Handbook is presented at the volunteer interview.

I acknowledge I have received the Tulsa Area Chapter policies listed below. It is my responsibility to read and understand the contents of these items.

I understand if I need clarification of the Tulsa Area Chapter policies, my supervisor and the Volunteer Services department is available to answer my questions. It will be my responsibility to attend all mandatory training classes sponsored by the American Red Cross regarding its policies and procedures.

I am aware that any violation of the American Red Cross, Tulsa Area Chapter, policies and procedures may result in disciplinary action, leading up to and including termination.

GENERAL POLICY OF CONFIDENTIAL INFORMATION

AVOIDANCE AND RESPONSE TO WORKPLACE VIOLENCE POLICY

COMPUTER HARDWARE/SOFTWARE POLICY

HARASSMENT-FREE WORK ENVIRONMENT POLICY

DIVERSITY POLICY

INTELLECTUAL PROPERTY AGREEMENT

____________________________________		_____________________
Volunteer Signature		Date
____________________________________		_____________________
Volunteer Services Department		Date