Caregiver Application : Get Involved : A Spacious Place, Inc.

Because A Spacious Place: Creativity & Spirituality Center, Austin, Texas, cares for children and youth, persons 65 years or older, and adults with disabilities (collectively, “Protected Classes”), and desires to protect them, we ask you to answer the following questions. We understand the following questions are personal and will be held in confidence.

Application for Volunteer and Paid Workers

Applicant Information

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Primary Email

Primary Phone

Date of Birth

Vocation

Current Employer

Employment Status (optional for volutneer workers)

Part-Time
Full-Time
Student

Drivers License # (if you do not have a driver's license, we will consult with you on how we may obtain your background information)

State of Issuance

Personal and Spiritual History

Write briefly about significant events in your life that have impacted you spiritually.

How would you describe your spiritual journey now?

Are there any special issues or concerns happening in your life right now that would have an impact in your commitment and involvement with A Spacious Place’s Protected Classes? (e.g., relationships, other commitments, past issues etc.)

Legal and Lifestyle Concerns

In caring for Protected Classes, we believe it is our responsibility to seek a staff that is able to provide healthy, safe, and nurturing relationships.

Our policy is that any person who

presently uses or condones the use of illegal drugs or narcotics or abuses legal drugs; and/or
has ever had sexual relations with a minor since becoming an adult; and/or
has ever been arrested for, charged with, under probation for, or convicted of either sexual or physical abuse

will not be considered for a paid or volunteer worker position.

By submitting this application the respondent signifies that they qualify under this policy. Please answer the following questions honestly. Any special concerns can be discussed individually with the A Spacious Place staff or board.

Have you ever gone through treatment related to any of the following:

Alcohol abuse
Drug abuse
Other addictive disorders
Sexual misconduct
Psychological or physical abuse
None

If you have answered yes to the above, what are you presently doing to maintain your recovery?

Have you ever been convicted of a crime involving moral turpitude? (Moral turpitude relates to conduct that involves immorality or lack of integrity. Generally speaking, theft, perjury, vice crimes with intent [but not DWI], rape, conversion.)

If yes, please describe.

Were you a victim of sexual or physical abuse while a minor?

Is there any reason, including those that are physical or mental health related, that might keep you from effectively working with Protected Classes, or that might cause harm to a member of Protected Classes?

Additional Comments

Experience

List the dates and activities of your leadership/service/teaching experiences.

What talents, gifts, and abilities do you feel you have, and how would you like to use them in working with members of A Spacious Place’s Protected Classes?

I am particularly interested in working with: (Please check any that apply)

Infants
Toddlers
Older Preschoolers
Grades 1-5
Grades 6-8
Grades 9-12
Adults

Why do you want to volunteer with A Spacious Place’s Protected Classes? What are your expectations of the A Spacious Place staff and board?

Personal References

Please provide at least three (3) references not related to you. Your references will receive a reference request form and/or phone call (we will provide you a sample reference form on request). One or two references by someone who has direct knowledge of your work with members of Protected Classes. AND one or two references by someone who has known you for five (5) years or longer.

Name

First Name *

Last Name *

Relationship

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Years Known

Email Address

Primary Phone Number

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Name

First Name *

Last Name *

Relationship

Years Known

Email Address

Primary Phone Number

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Name

First Name *

Last Name *

Relationship

Years Known

Email Address

Primary Phone Number

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Name

First Name

Last Name

Relationship

First Name

Last Name

Years Known

Email Address

Primary Phone Number

Address

Country

Address Line 1

City

State/Province

Postal Code

Policy Agreement

Download A Spacious Place Policies Document

I have downloaded, read, and/or viewed, understand, and agree to comply with the A Spacious Place, Incorporated’s policy and procedure for reducing the risk of abuse against children and youth, persons 65 years or older, and adults with disabilities.

I have received a copy of the A Spacious Place policy, which includes the government website address detailing the procedure for reporting abuse.

Name

First Name *

Last Name *

Date

The information contained in this application is correct to the best of my knowledge. I authorize A Spacious Place: Creativity & Spirituality Center, or its representatives to contact my references, churches, other organizations listed in this application, and appropriate government agencies as deemed necessary in order to verify my suitability as a Protected Classes’ worker. I also give A Spacious Place: Creativity & Spirituality Center permission to conduct a criminal background check. I authorize any references, churches or other organizations listed in this application to give A Spacious Place: Creativity & Spirituality Center, or its representatives, any information, including opinions, that they may have regarding my character and fitness for work with members of Protected Classes. In consideration of the receipt and evaluation of this application, I hereby release any individual, church, organization, charity, employer, reference, or any other person or organization, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application. I understand that the personal information in this application will be held confidential by the A Spacious Place: Creativity & Spirituality Center staff and board, and will only be accessible to its staff and board.

If being considered for a paid worker position, I consent to a Fair Credit Reporting Act investigation as indicated by my signature on the consent and release form attached hereto

Name

First Name *

Last Name *

Date

COME CELEBRATE OUR 20TH YEAR OF SERVICE!

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