Volunteer Application







Horton’s Kids Volunteer Application

Page 1

General Information

555-555-5555

Volunteer Interests and Experience

Employer

555-555-5555

Background
To protect the children participating in our programs, Horton’s Kids, Inc. conducts a background check of all volunteers. Please provide the information below. We thank you for your cooperation in maintaining a safe environment for our children. 

Emergency Contact Information
In case of an emergency, who should be notified?

555-555-5555

The statements contained herein are true and complete, to the best of my knowledge. I
authorize investigation of all statements made in this application. I understand that I
shall have no right to examine any references obtained or information gathered
pursuant to my application. I release Horton’s Kids, Inc. and each individual acting on
its behalf from all liability relating to the investigation of the statements contained herein.
I will abide by the Code of Ethics for Volunteers, as amended from time to time.

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CODE OF ETHICS
1. Volunteers will never leave a child unattended. 

2. Except during an emergency situation, a volunteer is not to be alone with children and is never to be alone
with one child. 
3. Fraternizing (socializing or associating) with program participants who are under the age of 18 outside of
activities sponsored by Horton’s Kids is forbidden (such as babysitting, private lessons, etc.). Any exception to
this policy requires written approval by the President or designee. 
4. Volunteers will portray a positive role model for youth, including but not limited to, maintaining an attitude of
respect, loyalty, patience, courtesy, tact, and maturity. 
5. Volunteers must treat all children with respect and consideration. A volunteer may not treat a child differently
because of that child’s race, color, religion, sex, national origin, age, physical handicap, personal appearance,
sexual orientation, family responsibilities, source of income, or place of residence, except that accommodations
may be made to promote a child’s participation in activities sponsored by Horton’s Kids. 
6. Volunteers will not abuse children. Examples of prohibited abuse include: 
a. Physical Abuse – strike, spank, shake, slap 
b. Verbal Abuse – humiliate, degrade, threaten 
c. Sexual Abuse – including inappropriate physical contact 
d. Mental Abuse 
7. Volunteers will use positive techniques for guidance, including redirection, anticipation of and elimination of
potential problems, positive reinforcement and encouragement rather than competition, comparison or criticism. 
8. Using, possessing or being under the influence of alcohol or illegal drugs during activities sponsored by
Horton’s Kids is not allowed. 
9. Smoking or using tobacco products in the presence of children or parents during activities sponsored by
Horton’s Kids is not allowed. 
10. Volunteers will not use profanity in the presence of children or parents. 
11. Volunteers must appear clean, neat, and appropriately attired. 
12. Volunteers will refrain from intimate displays of affection toward others in the presence of children, parents
and other volunteers. 
13. Volunteers must be free of physical and psychological conditions that might adversely affect children’s
health, including significant fever or readily contagious conditions. 
I agree to abide by the Code of Ethics, as amended from time to time. I understand that any violation of the
Code of Ethics may result in my exclusion from future activities sponsored by Horton’s Kids. Click here to enter text

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The Program: Horton’s Kids is a 25-year-old organization that has provided comprehensive services to
thousands of Ward 8 children and their families. The organization’s goal is to connect children with critical
resources and opportunities they need to succeed through academic, enrichment, and health and basic
needs programs. Horton’s Kids provides healthy meals followed by one-on-one tutoring sessions for
participants to strengthen their math and literacy skills. Sessions take place through personalized tutoring
sessions on Monday and Tuesday evenings in the Rayburn House Office Building, and on Wednesday
afternoons at the U.S. Department of Education. 
I am aware that my participation as a volunteer in the program described above (the “Program”) involves
risk of injury. I understand that the risks will vary depending upon the activities planned. I understand that
certain activities (such as those involving water, running or other athletic activities) are inherently
dangerous and involve many risks of injury, including, but not limited to, serious bodily injury and death.
I have provided to Horton’s Kids all medical information that Horton’s Kids would need to know in the event
of a medical emergency, including all of my known allergies and other medical conditions. I have provided
all additional information that I consider important to my participation in the Program. I will adhere to all of
the rules, regulations and instructions given by Horton’s Kids, its officers, directors, employees, volunteers
and agents and I assume responsibility for my compliance with such rules, regulations and instructions.
In consideration for allowing me to participate in the Program, I hereby assume all the risks associated with
the Program and agree to hold Horton’s Kids, its officers, directors, employees, volunteers, and agents
harmless and indemnify them from any and all liability, causes of action, suits, controversies, obligations,
claims, debts or demands of any nature whatsoever which may arise in connection with my participation in
the Program, including, without limitation, those which arise though the negligence of the officers, directors,
employees, volunteers and agents of Horton’s Kids or of any other participant in the Program.

AUTHORIZATION AND RELEASE

I authorize and request every person, firm, company, corporation, governmental agency (including any
department of motor vehicles), law enforcement agency, court, association, or institution having any
control of any documents, records, or other information pertaining to me, to furnish Horton’s Kids, Inc.
any such information, including documents, records, charges, or complaints filed against me, including
any complaints erased by law, whether formal or informal, pending or closed, or any other data pertinent
to my fitness to work directly with children; and to permit Horton’s Kids, Inc. or any of its agents or
representatives to inspect and make copies of such documents, records, or other information. The records,
however, will not include any information with respect to juvenile offense. 

I hereby release, discharge, and exonerate Horton’s Kids, Inc., its agents and representatives, and any
person so furnishing information from any and all liability of every nature and kind arising out of the
furnishing or inspection of such documents, records, and other information or the investigation made by
Horton’s Kids, Inc.



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