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Name
Address
Birth Date
How did you hear about Michael’s Place?
What type of volunteer work are you interested in? Please check one or more of the choices below.
Have you ever been convicted of any felonies or misdemeanors (other than for a minor traffic offense)?
Are you interested in being a facilitator and/or working with the children?
Have you experienced the death of a family member(s) or close friend(s)?
Have you previously attended support group programming at Michael’s Place?
Do you have clinical certifications or degrees?
Do you have previous and/or current experience as a volunteer?

Confidentiality and Indemnification

Board Members, staff members and volunteers will, to the best of their ability, ensure confidentiality and privacy with regard to history, records, and discussions about clients and donors. Therefore, all volunteers are required to sign a confidentiality acknowledgment stating their responsibility and commitment with regard to client and donor information. Disclosure can be made only under specified conditions which are described below, for reasons related to law enforcement and fulfillment of our mission. Staff members, board members, and volunteers shall not disclose any information about a person, including the fact that the person is or is not served by Michael’s Place, or has or has not donated to Michael’s Place, to anyone outside of this organization unless authorized by the Program Director or Executive Director. This principle of confidentiality must be maintained in all programs, departments, functions, and activities.

  • No information requested by someone other than staff or board members regarding whether a person is or has been served by Michael’s Place or has donated to Michael’s Place will be given. Volunteers are instructed to respond to such requests with the statement: “Michael’s Place policy does not permit me to give out that information.”
  • Release of information forms will be explained and signed by the person about whom any information is to be released, before it is released.
  • The taking of notes, copying of records or removal of records is strictly prohibited unless a release of information form has been properly completed.
  • Volunteers will not discuss any individual’s record with unauthorized individuals.
  • Volunteers will not release or make copies of copyrighted and trademarked information regarding the Benevon Model of Sustainable Funding with individuals other than board or staff members of Michael’s Place.
Confidentiality Agreement
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