Name: __________________ ________________ Today’s Date:__ __/__ __/__ __ __ __ Last First Month Day Year

GENERAL INFORMATION

Current Address: _________________________________ Date of Birth: __ __/ __ __/ __ __ __ __

City: _____________________ State/Zip: _______________ Primary Phone: ______________

Alt. Phone: ________________ Church: ___________________ ☐ Cell ☐ Home ☐ Work (Please Check)

E-Mail:___________________________ How did you learn of Urban Impact?___________________

Permanent Address (if different from above): _____________________________________________

Preferred Communication Method: ☐ Phone Call ☐ Text Message ☐ E-Mail Shirt Size:_________

Medical Information: Self pay/No insurance

Company: _______________________________ Policy Number: _____________________________

Health Concerns (describe concerns and/or check off boxes below): __________________________________

Diabetes Physical Handicap Emotional Handicap Asthma Insect Stings Seizures Nervous Disorders Cardiac Hay Fever Epilepsy Other __________________________________

Activity Restrictions ___________________________________________________________________

Emergency Contact:

Name: ____________________ Relationship: _______________ Phone: ____________________

MINISTRY How would you like to be involved at Urban Impact? Please mark your preferences with a √.

I would like to be an/a:

Indirect volunteer Administrative/office work, non-relational interaction with Urban Impact participants Direct volunteer

Relational interaction with participants within the program environment only. Discipleship mentor

Interacting with participants in a discipleship relationship in and outside the program environment.

For the following areas/programs:

Academics - Weekday mornings or afternoons Athletics - Weekday evenings (6-8:30pm) and/or Saturdays (10am-12pm or 2-4pm) Performing Arts - Tuesday (6-9pm) and/or Thursday (3:30-9:00pm) Summer Day Camp Monday Nights

- Monday thru Friday (June – August)- Monday (6-9pm, June-August)

Special Events Marathon Football Clinic Athletics Banquets Concerts & Performances (circle all that apply)

Rank in order of preference the age groups with which you are most comfortable. pre-school elementary school middle school high school no preference

How often would you like to volunteer? 1. weekdays weekday evenings weekends 2. one day a week less than one day a week more than one day a week 3. ongoing program special events

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UIF VOLUNTEER RELEASE AND WAIVER OF LIABILITY

PLEASE READ CAREFULLY

I, , the volunteer, herby freely and voluntarily, without duress, execute this Release under the following terms:

Waiver and Release. I hereby release and forever discharge and hold harmless Urban Impact Foundation and its successors and assigns from any and all liability claims, demands, and causes of action, of whatever kind of nature, either in law or equity, which may hereafter arise from my participation.

I understand and acknowledge that this Release discharges Urban Impact Foundation from any liability or claim that I may have against Urban Impact Foundation with respect to any bodily or other injury, illness, death or property damage that may result from my participation as a volunteer. I also understand that Urban Impact Foundation does not assume any responsibility or obligation to provide financial assistance, including, but not limited to, medical, health, or disability insurance, in the event of injury, illness death, or property damage.

Insurance. I understand that except as otherwise agreed in writing, the Urban Impact Foundation does not carry or maintain health, medical, disability, damage, liability, or other insurance coverage for the benefit of any volunteer and expressly disclaims the responsibility or obligation to so. As a volunteer, I am expected and encouraged by Urban Impact Foundation to maintain medical, health, and all other applicable insurance coverage for my own benefit.

Medical Treatment. I hereby release and forever discharge Urban Impact Foundation from any and all claims, demands and causes of action whatsoever that may arise or may hereafter arise on account of any first aid or other medical treatment rendered in connection with volunteer activities.

Assumption of Risk. I understand that my participation with Urban Impact Foundation and/or any project, activity or event sponsored, managed, arranged or promoted by, or otherwise affiliated or associated with Urban Impact Foundation may include activities that may be hazardous to me. I further recognize and understand that such participation may involve certain inherently dangerous activities. I hereby expressly and specifically assume the risk of injury or harm in the activities and release Urban Impact Foundation from all liability for injury, illness, death and/or property damage that may result.

Photographic Release. I release Urban Impact Foundation to use photos, video, and audio of myself in promotional materials that support UIF & its programs as well as any media coverage that may occur. I release UIF from any liability connected with the use of my picture or voice recording as part of any promotional, recruitment or fundraising program.

Other. I expressly understand and agree that this Release is intended to be as broad and inclusive as permitted by law, and that this Release shall be governed and interpreted in accordance with the laws of Pennsylvania. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release.

This Release is entered in to voluntarily and knowingly on _______________________. [Date]

Volunteer Signature Date

Print Name

Witness Date

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If checking ‘Box 1,’ please submit a copy of your ‘Declara on Page’ of auto

insurance coverage to Urban Impact at your earliest convenience

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Greetings Prospective Volunteer, 

Thank you for your interest in fulfilling Christ’s Great Commission through volunteering with Urban Impact! This letter details how UIF brings volunteers into compliance with all PA Child & Protective Services Laws. 

Based on the requirements of the law, PRIOR to volunteering with any UIF event, volunteers must have the following background checks completed, and the results reviewed by Urban Impact staff: 

Pennsylvania Criminal Record Check (Act 34)  [complete Justifacts form on page 5] Pennsylvania Child Abuse Clearance (Act 33) [Apply online by following the step‐by‐step instructions on

pages 9 to 11] Note: You will need to receive a payment code from Urban Impact FBI Fingerprintingo Note: Prospective volunteers who have resided continuously within Pennsylvania for no fewer than the

past 10 years, may be eligible to sign the enclosed disclosure statement found on pages 7 and 8of this application, in lieu of completing the fingerprinting requirement.  If you have not lived inPennsylvania for 10 consecutive years complete the fingerprinting registration form on page 6)

To provide the safest environment possible for our youth, Urban Impact goes above the requirement of the law and also requires volunteers to have the following background checks completed, and the results reviewed by Urban Impact staff PRIOR to volunteering for an UIF event: 

Federal, District, and Department of Motor Vehicle background checks (no additional form required)

Individuals who have not had the required background checks run in the last 48 months will not bepermitted to volunteer until all required clearances have been brought into compliance.

Prospective volunteers who have recently had background checks run, whether FBI Fingerprinting, PACriminal, or PA Child Abuse, are welcome to furnish and submit a copy of any of these clearances to UrbanImpact staff, as long as they were completed less than 48 months ago.

All past convictions of any nature must be disclosed on the form titled ‘Notification and Authorization toConduct a Background Investigation.  Failure to disclose a past conviction of any nature will result in therejection of a prospective volunteer.

Applicants disclosing a past conviction are required to meet directly with Urban Impact prior to beingcleared to volunteer, in order to assess whether they will be eligible to volunteer at the present time

Applicants convicted of the following violations are not permitted to volunteer with children under anycircumstance: Crimes against children, murder, armed robbery, and rape.  All violations not listed here aresubject to both Act 153 and Urban Impact’s volunteer violation guidelines, and may require the completionof set prerequisites prior to one being fully cleared to volunteer.

All prospective volunteers are strongly encouraged to contribute towards all or a portion of the cost incurredby Urban Impact to run their background check clearances.  On average it costs upwards of $40 to run all stateand organizational required clearances on a new volunteer applicant.  Any donation received allows us todedicate more funds directly towards transforming the lives of our participants.

Contribution made to Urban Impact are tax deductible If donating by check, please make payable to Urban Impact Foundation

By signing below, applicant has read the terms of Urban Impact’s volunteer background check policies, and will abide by the conditions and requirements set forth: 

(Signature)  (Today’s Date) 

(Print Name) 

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__________________________________

__________________________________

_________________________________

___________________________

___________________________

_______________

______________

_____ _____

_______

___________________________________________________

______ / ______ / _________

________ — ______ — __________

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DISCLOSURE STATEMENT APPLICATION FOR VOLUNTEERS Required by the Child Protective Service Law

23 Pa. C.S. Section 6344.2 (relating to volunteers having contact with children)

I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a clearance through the Federal Bureau of Investigation, as:

the position I am applying for is unpaid; andI have been a resident of Pennsylvania during the entirety of the previous ten-year period.

I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.

I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statues or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.

Chapter 25 (relating to criminal homicide) Section 2702 (relating to aggravated assault) Section 2709 (relating to stalking) Section 2901 (relating to kidnapping) Section 2902 (relating to unlawful restraint) Section 3121 (relating to rape) Section 3122.1 (relating to statutory sexual assault) Section 3123 (relating to involuntary deviate sexual intercourse) Section 3124.1 (relating to sexual assault) Section 3125 (relating to aggravated indecent assault) Section 3126 (relating to indecent assault) Section 3127 (relating to indecent exposure) Section 4302 (relating to incest) Section 4303 (relating to concealing death of child) Section 4304 (relating to endangering welfare of children) Section 4305 (relating to dealing in infant children) Section 5902(b) (relating to prostitution and related offenses) Section 5903(c) (d) (relating to obscene and other sexual material and performances) Section 6301 (relating to corruption of minors) Section 6312 (relating to sexual abuse of children), or an equivalent crime under Federal law or the law of another state.

I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance, drug device and cosmetic act) committed within the past five years.

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I understand that I shall not be approved for service if I am named as a perpetrator of a founded report of child abuse within the past five (5) years or have been convicted of any of the crimes listed above or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.

I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law as listed above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database.

I understand that if the person responsible for employment decisions or the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the person responsible for employment decisions or administrator of a program, activity or service shall immediately require me to submit current clearances obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of clearances shall be borne by the employing entity or program, activity or service.

I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position.

I understand that the person responsible for employment decisions or the administrator of a program, activity or service is required to maintain a copy of my clearances.

I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code.

Name: ____________________________Signature:________________________________

Witness: ____________________________Signature:_________________________________

Date: ________________________

(Disclosure statement provided by the Pennsylvania Department of Human Services, Office of Children, Youth and Families.)

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PA Child Abuse Clearance - Online Instructions [Detach and Complete Instructions on pages 9 thru 11]

>> ATTENTION PROSPECTIVE VOLUNTEER: We ask that you apply online for your state required ChildAbuse Clearance, as the turnaround time for online applicants is weeks faster than when processed bymail.  The application process should take you roughly 15‐20 minutes.

When you are ready to apply, please contact the Urban Impact department you will be volunteering in to receive an individualized payment code:   

‐ ATHLETICS: Andrew Churchill – andrew.churchill@uifpgh.org or 412‐321‐3811 x107 ‐ EDUCATION: Laura Maffeo – laura.maffeo@uifpgh.org or 412‐321‐3811 x113 ‐ PERFORMING ARTS: Kim Tryon – kimberly.tryon@uifpgh.org or 412‐513‐4760 x7400 

Once you have your payment code, please proceed with the online steps below: 

Go to: https://www.compass.state.pa.us/cwis/public/home

You must first create an Individual Account:

Choose Create an individual Account – You should see this screen next. 

Select “Next” button at bottom of screen.

Enter your profile information including security questions.

Click “Finish” when you have completed all required information.

You should see this screen next:

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Once you retrieve your Temporary Password…  

Return to: https://www.compass.state.pa.us/cwis/public/home and choose “Individual Login” On the next screen, select “ACCESS MY CLEARANCES”

 

After clicking “Continue” at the bottom right of the ‘Learn More’ screen, you should now see this page:

                

Put in the username you created and the temporary password (from the email)

You will then be required to set your own password…                 

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Once you set your own password, you will be required to login again. Return to:

https://www.compass.state.pa.us/cwis/public/home  

You’ll have to go to bottom of page and select the “I have read. . . “ option and  

I have read, fully understand and agree to the My Child Welfare Account Terms and Conditions  

I do not accept the My Child Welfare account Terms and Conditions  

Choose “Next” on bottom of page. Then “Continue” on the bottom of next page. You should see this

page. Select “Create Clearance Application”

You should now be able to read and follow the prompts. Choose “Next” at the bottom of this page.

Please Note: You will be required to submit past address information, along with current and former household members as far back as 1975.

You will be able to save what you have completed if you are unable to complete the application in one sitting.

When prompted, enter the individualized payment code you received from Urban Impact so that you

will not be charged to submit your application.

Make sure that you select to have your results sent to Urban Impact also, so that copies of your results will be sent both to your residence and to Urban Impact.

If you have any questions, or something is not working correctly with the application website, please contact Andrew Churchill at andrew.churchill@uifpgh.org or 412-321-3811 x107.

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Name: __________________ __________________ Date: __ __/__ __/__ __ __ __ Last First Month Day Year

PART 2: Spiritual Journey

Please share briefly your conversion experience to saving faith in Jesus Christ:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Describe recent areas of recognized growth in your day-to-day Christian life:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever led anyone to Christ for the first time, or discipled someone so that they grew in their

walk with God? Explain how it happened most recently:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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Have you served or participated in any discipleship programs, mentoring relationships, or youth

ministries, whether presently or in the past?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

As representatives of Christ, we are urged in Ephesians 4:1 to ‘live a life worthy of [our] calling.’ This

includes resisting lifestyles and temptations that our society may deem acceptable. What decisions

have you made, and boundaries you’ve set--in order to honor God and live a life above reproach?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Please share your motivation(s) in desiring to volunteer with Urban Impact:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

THANK YOU FOR SHARING A GLIMPSE OF YOUR RELATIONSHIP WITH CHRIST!

PLEASE CONTINUE ON TO OUR DOCTINAL BELIEFS…

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Name: __________________ __________________ Date: __ __/__ __/__ __ __ __ Last First Month Day Year

PART 2 Cont’d: Organizational Doctrine

At UIF we believe everyone is in process with the Lord. Our understanding of God is one of those areas we are constantly growing in. We are interested in where you are on your journey.

Please read the following beliefs about God which UIF affirms. After reading, please respond in the space provided with the following: (1) Are these beliefs consistent with your own beliefs? (2) Which, if any of these beliefs do you remain unsure about? Why so?

NOTE: PLEASE DO NOT WRITE MORE THAN 250 WORDS PER STATEMENT.

ABOUT THE SCRIPTURES: We believe the entire Bible is the inspired Word of God and that men were moved by the Spirit of God to write the very words of Scripture. Therefore, we believe the Bible is without error in its original manuscripts.

ABOUT GOD: We believe in one God who exists in three distinct persons: Father, Son, and Holy

Spirit. ABOUT JESUS: We believe that Jesus Christ is fully God and fully human. We believe that He

was born of a virgin. We believe that He lived a sinless life. We believe that His miracles were true. We also believe that He died in the place of sinners on a cross, that He was truly resurrected, and ascended back to heaven.

ABOUT THE HOLY SPIRIT: We believe in the personality and deity of the Holy Spirit. We

believe He gives life, He sanctifies, He empowers and comforts all believers. We believe the Holy Spirit indwells believers in Christ. We believe that it is through the power of the Holy Spirit that we are born again, and that the work of the Spirit includes convicting us of sin and empowering us to be righteous.

ABOUT MANKIND: We believe that mankind was created in the image of God. God gave

Adam, the first man, specific commands that were to be obeyed. Through his sinful disobedience to these commands, Adam and the whole human race were alienated from God. As a result, man is incapable of regaining a right relationship with God through his own effort.

ABOUT SALVATION: We believe that, as a result of The Fall, all men are lost and separated

from God because of sin. For this reason, we believe that man is saved only through repentance and faith in the finished work of Christ. Therefore, in order to experience salvation, even those who have never heard the name of Jesus Christ must hear of Christ and understand who He is to be saved. We believe that, when we repent and express faith in this manner, we are declared not guilty before God by His grace alone, are born again, receive the gift of eternal life, and become children of God.

ABOUT THE CHURCH: We believe the Church is the body of Jesus Christ, and it is composed of all true believers, with Christ as the Head of the body. We believe that, while on earth, believers must join themselves to other Christians in visible local assemblies. We believe these local assemblies are also the Church, for it is in these local assemblies that the work of the

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Church is carried out. The present work of the Church is the worship of God, the loving and teaching of people, and making Him known to a lost world. We believe the purpose of the Church is to glorify God.

ABOUT CHRIST'S RETURN: We believe in the personal and bodily return of the Lord JesusChrist. His return will complete and establish the ongoing enjoyment of our salvation in His glorious Kingdom.

__________________________________________________________________________________

1) Are the beliefs stated above consistent with your own beliefs: (Circle One)

YES NO SOMEWHAT

2) [If selecting ‘No’ or ‘Somewhat’ above] Which, if any of these beliefs do you remain unsure about? Why so?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

THANK YOU FOR APPLYING TO VOLUNTEER AT URBAN IMPACT, AND SHARING A GLIMPSE OF YOUR RELATIONSHIP WITH CHRIST!

PLEASE RETURN YOUR COMPLETED APPLICATION TO URBAN IMPACT BY MAIL, SCANNED EMAIL, FAX, OR IN PERSON AT THE URBAN IMPACT OFFICE BETWEEN 9:00AM-5:30PM.

MAIL: Urban Impact  

801 Union Avenue, 4th Floor Pittsburgh PA 15212

FAX: 412-321-2369 PHONE: 412-321-3811

ATHLETICS: andrew.churchill@uifpgh.org EDUCATION: laura.erb@uifpgh.org OPTIONS: sara.kimler@uifpgh.org

PERFORMING ARTS: kate.clark@uifphg.org

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