Chains Interrupted · Chain Breaker Application

Contact Information

Name *

First Name

Last Name

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone *

Email

Verify Email

Date of Birth *

(mm/dd/yyyy)

Gender *

Man

Woman

Other

Spouse's Name

First Name

Last Name

Education/Employment/Experience

Organization/Employer *

Occupation *

Are you a member of any Churches, Social Clubs, or Civic Organizations? *

Why do you want to volunteer, and have you had any previous experience with Chains Interrupted or Anti-Human Trafficking? *

Do you have any special skills, credentials, or traning that could be relevant to Chains Interrupted? *

Referral Source

Availability

Availability *

We understand availability changes throughout the year! Please select what you feel is most accurate to you currently:

Morning

Afternoon

Evening

Weekdays

Weeknights

Weekends

Volunteer Opportunities

At Chains Interrupted, our volunteers play a big role in the work we do. Our needs are ever changing, so our volunteers help us to do a number of different things. We cannot always be sure what opportunities we will have for you, but here is a list of a few things our volunteers have done in the past to help you better understand what you could be doing:

Administrative work, graphic design, merchandise delivery, public speaking, event planning, hotel/motel outreach, social media, fundraising, IT/tech, outreach (booths/parades), thank yiou writing, grant writing, maintenance/repair, video filming/production and more!

By filling out this application, you are letting us know you are interested in helping out in some of these areas!

Emergency Information

Emergency Contact *

Relationship *

Emergency Contact Phone Number *

Do you have any medical needs, or specific accommodations we should be aware of (limitations, allergies, conditions, etc.)? *

Background Check Policy

Chains Interrupted will make every reasonable effort to provide a safe environment for clients, staff and volunteers. *Chains Interrupted preforms a criminal background check via Iowa Courts Online and the Iowa Sex Offender Registry for volunteers. Please initial below to indicate you read and understand this policy:

Initials: *

*There is a charge of $15 to conduct a background check. We do not want this expense to stand in your way of working with us and will cover it if this would be a hardship for you.

$15 - I will cover the cost of the background check.

Have you ever been convicted of a crime in Iowa or any other state? Include criminal charges pending and simple misdemeanors. *

If yes, please explain *

If no, enter N/A

Please note - this form is not a background check. After completing this Chain Breaker Application, our outreach coordinator will be in contact with you. They will provided you with a form to fill out in order to submit a background check.

Release

As a part of my participation, I grant permission to the Chains Interrupted to use my
photograph. This includes still or motion picture, and the recording of my voice. These
photographs/recordings may be used for advertising and publicity purposes. I hereby release
Chains Interrupted, any affiliated organizations, their directors, officers, agents, and
employees, for all claims of every kind on account of such use.

Intials *

Full Name - *This is the equivalent to a hard copy signature *

First Name

Last Name

File Upload

Confidentiality Agreement

Chains Interrupted (CI) staff and volunteers are required to abide by the following guidelines regarding privacy & rights of clients, donors & members of CI staff, intern/work study & volunteers. CI staff and volunteers have the responsibility to (please initial each one):

Ensure that private information (such as names, all contact information, social security numbers, insurance information, pay information, performance information, medical and/or health information, donation amounts, and personal contact information) regarding staff, interns/work – study, volunteers, clients, and donors is protected and kept private. This includes ensuring that such sensitive information is stored in a secure place, and is never left unattended in an area in which it could be accessed without authorization. (Such as on a computer screen, printer, or fax machine.)

Enter Initials: *

Never disclose to any third party any data, under any circumstances, without the consent of the CI employee that is supervising you and the Executive Director materials, knowledge and information generated through, originating from, or having to do with CI or persons associated with our activities, including contractors, client information, including all file information, this is to be considered privileged and confidential. All pages, forms, information, designs, documents, printed matter, policies and procedures, conversations, messages (received or transmitted), resources, contacts, e-mail lists, e-mail messages, client, staff or public information is confidential and the sole property of CI.

Enter Initials: *

Store or dispose of professional records in ways that maintain confidentiality and the integrity of CI. For example, shred documents containing sensitive information before recycling.

Enter Initials: *

Maintain a professional attitude, which upholds the confidentiality of the clients we serve, colleagues, applicants, and co-workers as well as any sensitive situation arising within the organization.

Enter Initials *

Avoid accessing information, electronically or otherwise, which is not necessary to the completion of one’s role as a volunteer.

Enter Initials: *

Never speak to the media on behalf of CI unless authorized to do so.

Enter Initials: *

Upon termination of employment, internship or volunteer program, shall maintain confidentiality and shall hold confidential any information concerning sensitive situations within the Organization.

Enter Initials: *

Any disclosure, misuse, copying or transmitting of any material, data or information, whether intentional or unintentional, will subject you to disciplinary action and/or prosecution, according to the procedures set by CI and any applicable laws.

My *typed* signature signifies I agree to these terms and will abide by, adhere to and honor all the above.

Full Name - *This is the equivalent to a hard copy signature *

First Name

Last Name

Today's Date *

(mm/dd/yyyy)