Volunteer Application

MM slash DD slash YYYY
MM slash DD slash YYYY
Please list your current and/or previous employment:
Do you have any health problems or physical disabilities which would prevent you from performing certain kinds of work?
Have you ever been charged with any kind of criminal activity?
Please indicate the specific time(s) and day(s) you would be available to volunteer:
Skills Survey

Options for Women St. Croix Valley values the strengths and skills of our volunteers to help achieve our mission. Please indicate areas in which you have skills and/or experiences that you would be willing to offer Options for Women St. Croix Valley. Write additional ways you desire to serve if they are not listed.

Skills Survey

My signature below indicates that the information I have included in this application is true and accurate to the best of my knowledge.

Policies and Values

  1. Life begins at conception.
  2. Every human life is valuable, regardless of its form or condition. To each individual
    belongs the right to live, to be honored in their individuality, and to have their basic
    needs met. We are advocates for the unborn, their parents, and their family.
  3. We do not perform, promote, or refer for abortion services. We are committed to
    strengthening individuals, families, and communities so that every human life will be
    welcomed and honored.
  4. In recognizing the sacredness of human sexuality, we are committed to preserving the
    integrity of individuals and couples. We teach only natural, non‐chemical, non‐surgical
    methods of family planning for married couples. We do not advocate any form of
  5. For single individuals, we teach fertility awareness, promote abstinence, and encourage
    self‐control and self‐respect.
  6. All services provided, whether material or in the form of counsel and support, are
    available to clients and patients free‐of‐charge. All services are confidential, except in
    cases where there is threat of harm to self or others, and statutory requirements for
    reporting abuse or neglect of a minor.
  7. Clients are treated with compassion, sensitivity, and respect.
    Your signature below indicates you understand all the policies listed above and promise both to
    follow and promote these practices while volunteering with or representing Options for Women
    St. Croix Valley.

Volunteer Code of Conduct

As a volunteer, I promise to follow the rules and guidelines in this Volunteer Code of Conduct as a condition of my providing services for Options for Women St. Croix Valley.

During the time(s) when I am directly serving in my role as a volunteer for Options for Women St. Croix Valley,

I will:
  • Treat everyone I serve with respect, loyalty, patience, integrity, courtesy, dignity, and consideration.
  • Use positive reinforcement rather than criticism, competition, or comparison when working with patients/clients or their children.
  • Maintain confidentiality in all matters.
  • Comply with the mandatory reporting regulations of the State of Minnesota to report suspected child abuse. I understand that failure to report suspected child abuse to civil authorities is against the law. Any suspected abuse should be reported to the Options for Women St. Croix Valley executive director, and he or she will contact the appropriate authorities on my behalf. I will cooperate fully in any investigation of abuse of children, youth, or vulnerable adults.
I will not:
  • Touch or speak to any child, youth, or vulnerable adult in an inappropriate manner.
  • Strike, spank, shake, or slap anyone I encounter.
  • Humiliate, ridicule, threaten, or degrade anyone I encounter.
  • Accept gifts from or give gifts to children, youth, or vulnerable adults without knowledge of their parents or guardians
  • Smoke or use tobacco products while engaging in volunteer activities with children, youth, or vulnerable adults.
  • Use, possess, or be under the influence of alcohol or illegal drugs.
  • Use profanity in the presence of children, youth, or vulnerable adults.

I understand that as a volunteer I may be subject to a thorough background check including criminal history. My signature confirms that I have read this Volunteer Code of Conduct and that while directly serving as a volunteer I agree to follow the above standards. I understand that any action inconsistent with this Code of Conduct or failure to take action mandated by this Code of Conduct may result in my removal as a volunteer.

Confidentiality Policy

Commitment to confidentiality is highly valuable and is promised to patients/clients in our advertising literature and verbal exchanges. Therefore, it is incumbent upon the center staff and all volunteers to honor that commitment to our patients/clients.

  1. Discussion of specific patient/client situations or interactions should be treated with utmost confidence and limited to those who are directly involved in the patient/client’scare.
  2. Communication of detailed information will be limited to the director and/or others within Options for Women St. Croix Valley staff who are directly involved with patient/client services.
  3. It may be appropriate on occasion to review generalized patient/client‐based interactions between clinic staff and volunteers, but care must be taken to ensure these reviews are for the purpose of mutual learning and edification. In these situations, names and identifying details must be excluded unless the patient/client has given permission otherwise.
  4. Information concerning patients/clients should never be revealed to persons outside of Options for Women St. Croix Valley other than in general, non‐identifying terms. An exception to this policy would be cases of imminent danger to self or others or child‐ protection concerns, which must be directed to law enforcement or the appropriate authority.
  5. If it is advantageous to share specific information with other agencies in the interest of better service provision, it must be with the patient/client’s expressed permission, in writing and in the form of a release. Even then, it is advisable not to share extensive information unless it is deemed necessary in carrying out essential services for the client.
  6. There are circumstances where concern for the safety and welfare of individuals may override the standard of confidentiality. Such a decision should never be made without the knowledge and approval of the director.

I agree to uphold the terms of the policy both while I am working in the capacity of staff or volunteer at Options for Women St. Croix Valley, as well as outside of this role in all that pertains to my work at Options for Women St. Croix Valley.

Parent/Guardian Permission Form

By signing below, I give permission for my child to volunteer at Options for Women St. Croix Valley. I also give permission for the staff of Options for Women to contact my child by phone/text/email (as listed in intake information above) for volunteer purposes only.

This field is for validation purposes and should be left unchanged.