rejection of this application or for immediate discharge if I have been selected to volunteer,
regardless of the time elapsed before discovery.
Initials I hereby authorize AVA to thoroughly investigate my references, work record, education,
criminal record, and other matters related to my suitability for a volunteer position In addition,
I hereby release AVA, my former employers, and all other persons, corporations,
partnerships, and associations from any and all claims, demands, or liabilities arising out of
or in any way related to such investigation or disclosure.
______ I understand that nothing contained in the application, or conveyed during any interview
Initials be granted or, if hired, during my volunteer experience at AVA, is intended to create a
volunteer contract between AVA and me. In addition, I understand and agree that if I am
selected as a volunteer, my volunteer tenure is for no definite or determinable period and
may be terminated at any time, with or without prior notice, at the option of either myself or
AVA, and that no promises or representations contrary to the foregoing are binding on me or
AVA unless made in writing and signed by me and the AVA designated representative.
______ Should a search of public records (including records documenting an arrest, indictment,
Initials civil judicial action, tax lien or outstanding judgment) be conducted or obtained by AVA, I
may be entitled by law to copies of any such public records obtained by AVA unless I mark
the check box below. If I am not hired as a result of such information, I may be entitled to a
copy of any such records even though I have checked the box below.
____ I further understand all information received as a result of the AVA office inquiries Initials
will be held in strict confidence, and any information received by the program in this
regard shall not be released to the applicant.
_____ I understand that my records are protected under the Federal Confidentiality
Initials Regulations and cannot be disclosed without my written consent unless otherwise
provided for in the regulations. I also understand that I may revoke this consent at any time
except to the extent that action has been taken in reliance on it and that in any event this
consent shall automatically expire upon my termination of involvement with the AVA
I waive receipt of a copy of any public record described in the paragraph above.
PURSUANT TO FEDERAL CODES, DISCLOSURE OF CLIENT INFORMATION IN A MANNER
NOT AUTHORIZED BY 42 CFR PART 2 IS A FEDERAL CRIMINAL OFFENSE PUNISHABLE BY
A FINE OF NOT MORE THAN $500.00 IN THE CASE OF A FIRST OFFENSE AND NOT MORE
THAN $5,000 IN THE CASE OF EACH SUBSEQUENT OFFENSE.
I HEREBY SUBMIT APPLICATION TO BE CONSIDERED AS A CASA VOLUNTEER AND
ATTEST THAT ALL THE INFORMATION HEREIN IS TRUE AND CORRECT.
Date Applicant’s Signature