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I have agreed to serve as a volunteer for the Horizons, A Family Service Alliance, and I recognize that my volunteer participation is a privilege afforded to me by the Horizons, A Family Service Alliance. I fully understand, appreciate and assume all of the risks associated with my volunteer duties. In exchange for my participation, I hereby agree to the following:

1. I voluntarily waive, release and hold harmless the Horizons, A Family Service Alliance, its elected and appointed officials, officers, employees, agents and other volunteers from any and all claims, causes of action and damages for bodily injury or death that I may suffer as a result of, or in any manner connected with, directly or indirectly, my participation as a Horizons, A Family Service Alliance volunteer when such bodily injury or death is the result of my own negligent or intentional acts or omissions or those of another volunteer. I understand that this waiver and release precludes my right to recovery of damages in the event I am injured in the course of performing my volunteer duties.

2. I shall defend, hold harmless and indemnify the Horizons, A Family Service Alliance, its elected and appointed officials, officers, employees, agents and other volunteers, from and against all damages, claims, liabilities, causes of action, judgments, settlements, costs and expenses (including, but not limited to, reasonable expert witness and attorney fees) that may at any time arise or be claimed by any person as a result of bodily injury, death or property damage, or as a result of any other claim or cause of action of any nature whatsoever, arising from or in any manner connected with, directly or indirectly, my negligent or intentional acts or omissions in performing my volunteer duties.

I have read, fully understand and agree to the assumption of risk, waiver, release, hold harmless and indemnification terms set forth above.

Relationship: Employer Screening as specified in Chapter 237 of the Iowa Code. Complete and return to Human Resources. Please allow minimum 24 hours to process. The results will be e-mailed to the employee requesting the background check. If further investigation is required by the D.C.I., allow 5-7 business days for the results.

If a criminal, dependent adult abuse, or child abuse conviction is reported by the D.C.I., additional investigation is required by the Department of Human Services. Allow 30 days for the results.

AN IOWA CRIMINAL HISTORY CHECK AND REGISTRY INFORMATION IS BEING REQUESTED ON:

I hereby give permission for the above requesting organization to conduct an Iowa Criminal History, Dependent Adult and Child Abuse Registry check with the Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.

Horizons employment policy is to process criminal, dependent adult and child abuse background checks on all prospective employees. If a candidate has lived outside the state of Iowa in the past three years background checks will be requested in the states where the candidate has resided.

Please complete the following information from the time you turned 18.

I hereby give permission for the above requesting organization to conduct a Criminal History, Child Abuse and Dependent Adult Abuse Registry check with the Division of Criminal Investigation for the residence states listed below. If this form is not acceptable by any/all of the states for authorization to process a background check, I agree to complete and return the required forms for that state(s).

It is the policy of Horizons, A Family Service Alliance to provide a safe, helping environment and service for our clients. Therefore, the Agency requires that criminal, child abuse and dependent adult abuse record checks and any other background information be completed on all who are considered for employment, internship, or volunteering at Horizons. Please complete the information below by checking the appropriate statement and adding additional information required.

Please note that charges that have been deferred will be visible in a criminal background history report as will non-convictions.

I understand that I am required to disclose this information. I further understand that falsification of this information is grounds for dismissal. If I begin working or volunteering at Horizons, A Family Service Alliance, I understand that I must advise the agency of additional convictions and complete appropriate paperwork.