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To become a Hollywood Dreams volunteer, please print out this application
package. It includes two items - an application and a criminal history check.
Fill out both items and return them to us at our post office box in North Bend,
Oregon.
Thanks.
Volunteer Program Application
Hollywood Dreams
(a Social and Leisure Club for People with Developmental
Disabilities)
P.O. Box 121
North Bend, OR 97459
Phone - 541-404-5842 Fax: 541-756-4520
First Name: ________________________________ Last Name:
_________________________
Are you over the age of 18 years? Yes No
Mailing Address:
_____________________City: _______________State:_____ Zip: _______________
Email Address:
________________________________________________________________________
Work Phone Number: ______________ Home Phone Number: _______________
Describe your experience with youth/young adult with disabilities?
Why would you like to be a volunteer?
What do you feel is the best way to help develop appropriate social
skills for youths and young adult’s with developmental disabilities?
What are your interests?
5. What skills do you think you can offer for interacting with youth and
adults with developmental disabilities?
Notice: In order to process this request, the applicant must sign below and
complete Section 2 of the attached DHS Criminal History
Request. I hereby grant Hollywood Dreams permission to check my
references, and civil & criminal records to verify any statement made on this
form and on the attached DHS Criminal History Request.
Signature: _____________________________________________
Date: ________________________
Please return this completed, signed application package to:
Hollywood Dreams
Volunteer Program
P.O. Box 121
North Bend, OR 97459
Date rec’d:
Rec’d by:
This form is used when the fitness determination will be
conducted by an AD.
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Section 1: Completed by AD |
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1
Name of AD, qualified entity and
mailing address: Type or print clearly |
2 Name of requesting qualified
entity:
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3 AD e-mail
address:
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4 AD phone:
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Other: |
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System of care
(CW) |
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5 SI job title:/description: |
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6 SI start date: |
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7 SI position status: (Check
all boxes that apply to this position) |
8 SI supervisor name, worksite
location, phone number: |
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Contact with children Contact with
teens
Contact with adults
Contact with elderly |
Care of relative MH special needs
DD special needs
Physical special needs |
Involves driving Volunteer
Paid |
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Section 2: Completed by subject
individual Please print
clearly |
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9 Name of subject individual:
(Last, First, Middle) |
10 Date of birth:
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11 Sex:
M F |
12 Social Security or INS
Number: |
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13 Maiden name, other names
used: |
14 Driver’s License or ID
Card: Number: State: |
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17 Home or message phone: |
18 Height / Weight:
/ |
19 Race or ethnicity:
(optional) |
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21 List all
arrests and charges that did not result in a conviction,
regardless of how long ago. |
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Date
Estimate if not known |
Charge or arrest |
City/ State |
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22 Name of requesting
qualified entity:
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23 Name of subject
individual:
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24 Social Security Number:
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Section 2: Continued |
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25 List all convictions,
regardless of how long ago.
Indicate if military or
federal conviction.
Use additional paper if necessary. |
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Date of conviction
Estimate if not known |
Crime
Include felonies, misdemeanors, probation
violations and failures to appear |
Location
City/State |
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I have read and
understand the instructions for completing this form. I understand
that a criminal history and background check will be completed on me
and the information may be shared with the person listed in Box 1. I
certify this information is correct and complete. I understand that
if I provide false or incomplete information, I may be denied the
position. I understand the check may be repeated during the time I
hold this position.
30 Signature: 31 Date:
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Probationary status granted (by AD only)
Yes No |
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AD Signature: Date:
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Instructions for Subject Individual
Read all instructions before completing form |
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The "subject individual" is
the person whose history is being checked. The subject individual must
complete Boxes 9 through 31. The "authorized designee" (AD) or "contact
person" (CP) is a person who helps with the check and who has
received training from DHS. Listing your social security number (SSN)
is optional. If you do not provide your SSN, fingerprints may be
required. If you do not have a SSN but do have an INS number, write your
INS number in Box 12.
Disclose all history. You must accurately and completely disclose
all history requested. This includes all felonies,
misdemeanors, probation violations and failures to appear. If you fail
to list any part of your history, you may be denied. Serious traffic
offenses, such as "Reckless Driving," "Driving Under the Influence of
Intoxicants" (DUII) and "Driving While Suspended" (DWS) must be
listed. "Failure to Appear," even for a minor traffic violation, must
be listed. If you are not sure if something should be listed, you should
list it. Be certain to include the date (approximate if necessary) and
location (city and state) of each arrest and conviction.
If you have history that you believe is "expunged" or removed from
your record, or a crime for which you have been pardoned but you do not
have documentation that it was removed, you should list it. A crime is
not removed from your record until you complete the formal process to
have it removed.
Arrests. In most cases, arrests alone will not result in denial.
If, however, you falsify or provide incomplete information, you may be
denied.
Federal crimes. List all arrests and crimes. In boxes 21
and 25, if the FBI was involved or if you know that it was a federal
crime, you must indicate it.
Violations. Minor traffic violations such as parking tickets,
speeding, or failing to stop at a stop sign or red light, are not
required to be listed. |
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If you have any criminal history,
you should provide the following information in Box 26:
Tell us what happened when you were arrested and/or convicted.
What did you have to do because of the arrest or conviction?
Serve probation? Pay restitution?
List any treatment, counseling program, alcohol or drug
rehabilitation, education, and training.
List employment demonstrating responsible behavior.
How is your criminal history relevant to your job or position?
How has your life changed since the criminal history?
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Why do you believe you are no longer a risk to vulnerable people?
Explain why you believe past bad behavior is not likely to recur.
Attach documentation to support the information provided.
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DHS Criminal Records Unit
PO Box 14870
Salem, Oregon 97309-5066
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OUTCOME |
Denial. You may be denied if
you were convicted of a crime, you falsify or fail to disclose requested
information, or you are a registered sex offender. You may be denied if
you have a probation violation, outstanding warrant, deferred sentence
or unresolved arrest. You may be denied if you are on probation. If you
are "denied" you may not hold the position/job and must be terminated
immediately. Failure to cooperate. If you do not cooperate with
this criminal-history process, your application may be closed without a
fitness determination and you will not have a right to appeal the
decision. |
Additional Information and Instructions
Authority . The
Department of Human Services (DHS) is authorized by state law to
complete criminal and other background checks on people who work,
volunteer or live with people who are vulnerable to abuse or
mistreatment. Vulnerable people include children, senior citizens and
persons with physical disabilities, developmental disabilities or mental
illness. A check may be required even if the person does not have direct
contact with vulnerable people.
Results. Results from this request are returned to the authorized
designee listed in Box 1. If the qualified entity has a contact person
but no authorized designee, DHS will complete the fitness determination
without returning LEDS information to the contact person.
Sources checked. In doing this check, DHS may use information
from the Driver and Motor Vehicle Division; Department of Corrections;
Oregon State Police; Federal Bureau of Investigation; and local, state
and federal courts. DHS may use information from other criminal justice,
corrections and law-enforcement agencies, and other state and local
government agencies. Fingerprints may be requested by the DHS Criminal
Records Unit (CRU). In some cases, we may check current and previous
employers.
Challenging state information. The subject individual may look at
the criminal history information (LEDS record) provided by the Oregon
State Police. If the subject individual wants to obtain a copy of the
record or challenge information in the record, the subject individual
must contact the Oregon State Police, (503) 378-3070, extension 330.
Challenging FBI information. The subject individual may challenge
the accuracy and completeness of information in the FBI record if he or
she believes it is incorrect. To obtain a copy or challenge the FBI
record, the subject individual must contact the Federal Bureau of
Investigation for information, (304) 625-3878.
Civil rights. Subject individuals may have rights under Title VII
of the Civil Rights Act of 1964. Discrimination by an employer on the
basis of arrests alone may violate federal law. Individuals wishing to
obtain information regarding civil rights should contact the Oregon
Bureau of Labor and Industries, (503) 731-4075, or the U.S. Equal
Employment Opportunity Commission (EEOC), 1-800-669-4000.
Rechecks. This background check process may be repeated by the
qualified entity at any time while the subject individual works, resides
or otherwise continues in this position. It is recommended that the
qualified entity request the subject individual to notify the qualified
entity if they are arrested or convicted for any misdemeanor or felony
after completing this form.
Questions? Call (888) 272-5545 (toll-free)
or (503) 378-5470 |
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Codes for Qualified Entity (Box 2) |
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A&D - Alcohol & drug ALF - Assisted
living facility
CW - Child welfare
DD - Developmental disabilities
DHS - Department of Human Services |
FH - Foster home RCF - Residential
care facility
RCH - Residential care home
RTF- Residential training facility
RTH - Residential treatment home |
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If you need this form in large print or in a different
format,
call the Criminal Records Unit toll-free:
1-888-272-5545. |
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