Board Member Application

Education - High School
Education - Business, Trade, or Technical
Education - College
Education - Graduate School

Signature: I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract. In the event of membership, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the agency. *

Declaration Form

(Criminal, Child Abuse & Violent Felony Charges & Convictions)

Federal policies mandate that all prospective employees sign a declaration prior to employment, which lists: 1) All pending and prior criminal arrests and charges related to child sexual abuse and their disposition. 2) Convictions related to other forms of child abuse and/or neglect; and 3) All convictions of violent felonies.

The declaration may exclude: 1) Traffic fines of $200 or less; 2) Any offense, other than any offense related to child abuse and/or child sexual abuse or violent felonies, committed before the prospective employee’s 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law; 3) Any conviction the record of which has been expunged under Federal or State law; and 4) Any conviction set aside under the Federal Youth Corrections Act or similar State authority.

Note: Individuals who declare, through this form, that they have been arrested, charged with or convicted of any of the offenses listed above are not automatically disqualified. CAPCA will review each case to assess the relevance of an arrest, charge or conviction prior to a hiring decision.

Volunteer Application

Telephone Numbers:
AFFIDAVIT: I certify that everything in this application is true and correct to the best of my knowledge. I understand that misleading or incorrect statements or consequential omissions may render this application void, or if accepted as a volunteer, would be cause for termination. I authorize individuals named above to give information regarding my character and qualifications, hereby releasing them from all liability for issuing such information
CAPCA’s policy states that all non-vaccinated individuals must wear a mask when inside CAPCA’s facilities. If you are vaccinated and choose to do so, please provide a copy of your original vaccination card to place with your application.


Confidentiality Policy

All personally identifiable information concerning employees, clients and parent/guardians (of a Head Start child) is kept confidential. Only CAPCA staff and authorized personnel (i.e., monitors, licensing or evaluation teams) have access to a client/child records. Clients are prohibited from reviewing any records other than their own. Parents or guardians are prohibited from reviewing any records other than their own child’s. Clients need to be aware that in order for staff to provide assistance or act as an advocate, some information may need to be given to other agencies or persons bonded by client confidentiality. Written consent by the client or Head Start parent/guardian must be obtained to release information to anyone not bonded by client confidentiality. Head Start staff will review records as needed to perform their assigned duties.

Records are kept in locked files when not in use. Employees reviewing records must insure that visual monitoring and confidentiality of such records is kept at all times. Any Head Start staff viewing data must sign the Confidentiality of Records and Person Obtaining Data form located in the front of the child’s record. Records are to be returned to locked files when completed.

In addition to information given by parents or guardians, information obtained by staff about a child, clients or their families, verbal or written, must be kept confidential as stated above.

Head Start employees, under State Law and Federal Register Policy N-30-356-1-30, are mandated reporters of suspected child abuse and neglect. Thus, information related to such a case involving a Head Start child will be reported as stated in the CAPCA Head Start Child Abuse Reporting Procedures. Employees and children may be interviewed by Child Care Licensing, child maltreatment investigators, or by law enforcement for investigative purposes and/or for determining compliance with licensing requirements.

I, the undersigned, hereby agree not to divulge any personally identifiable information or recordsconcerning any clients, children, families, or employee(s) without proper authorization.

Community Service’s Standards of Conduct Acknowledgement Form

All staff, consultants and volunteers will abide by the program's standards of conduct. These standards include:

(i) Refrain from stereotyping on the basis of gender, race, ethnicity, culture, religion or disability.
(ii) Follow program confidentiality policies concerning information about children, families and other staff members.

I, the undersigned, have read the Standards of Conduct and hereby agree to abide by them. I also understand that a violation of the Standards of Conduct will result in discontinuing my volunteer opportunities with the agency.

Thank you for agreeing to volunteer at CAPCA, the contribution of your valuable time is a special gift.


Place form in the Health Information file on site
File copy in Personnel file
Update annually