Volunteer Information Form

Name: Kansas Guardianship Program
Address: Manhattan, KS, 66503, United States
Telephone: 7855878555

A person interested in becoming a volunteer and serving as a KGP guardian or conservator completes a Volunteer Information Form (VIF). To become a volunteer, fill out the form below

Volunteer

1. Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County of Residence*
Work Phone*
Home Phone*
Cell Phone*
Email Address*
May you be contacted at work?
- Yes
- No
Preferred contact
- Phone
- Email
2. Education and Training
Denote the highest level completed:*
- High School
- College
- Graduate
Are you presently enrolled in school?*
- Yes
- No
If you are currently enrolled, list your school and course of study.
Other educational or training programs completed:
Family Information
Spouse/Partner*
First Last
Employment/Occupation*
Children*
3. Work History

List your last three employers
1. Present Employer
Position
City/State
Start Date of Employment
End Date of Employment
2. Previous Employer
Position
City/State
Start Date of Employment
End Date of Employment
3. Previous Employer
Position
City/State
Start Date of Employment
End Date of Employment
3. Information, History and Preferences
Do you have work experience and/or training in any of the following areas?
- Social Work
- Psychology/Counseling
- Medical/Health Care
- Mental/Behavior Health
- Substance Abuse
- Services/Supports for Adults
- Services/Supports for Children
- Law Enforcement/Criminology
- Education/Teaching
- News/Media/Public Speaking
- Church Work
- Community Outreach
- Other
If yes to any of the above, please describe:
If Other, please describe:
Community Activities and Memberships
1. Organization
Position Held
City/State
Start Date
End Date
2. Organization
Position Held
City/State
Start Date
End Date
3. Organization
Position Held
City/State
Start Date
End Date
How did you learn of the Kansas Guardianship Program?
Discuss why you are willing to serve as a court appointed guardian or conservator.
Are you currently (or have you ever) served as a guardian, conservator, representative payee, power of attorney or durable power of attorney for health care decisions?
- Yes
- No
Number Served
If yes, please explain.
Describe your skills and experiences which may be relevant to serving as a guardian or conservator.
Please describe your philosophy and beliefs on being an advocate.
Preferences and interests related to serving as a guardian or conservator. Check all that apply.
- Specific Person
- Female
- Male
- No Preferences
- Persons with Intellectual/Developmental Disability
- Persons with Mental/Behavioral Health
- Persons with Illness Related to Aging
- Persons with Other Intellectually Disabling Conditions
Name of Specific Person
In what geographical area are you willing to serve? List by community or county name.
Do you have access to reliable transportation?
- Yes
- No
If no, please explain.
4. Conflict of Interest

The role of a guardian or conservator is to advocate for and protect the rights of the person receiving guardianship or conservatorship services. The advocate must be free of any appearance of personal or employer conflict of interest, self- serving gain, compromising influences and loyalties. For this reason the KGP requests information on family members who may be employed by or providing services and supports to avoid any potential for conflict of interest when nominating a volunteer to serve as guardian or conservator.Identify immediate family member(s) employed by a company or organization which provides individuals with services and supports (for example, nursing home, community mental health center, community developmental disability organization, community service provider, home health, etc.).
1. Name of Family Member
Relationship
Company Where Employed
2. Name of Family Member
Relationship
Company Where Employed
3. Name of Family Member
Relationship
Company Where Employed
Please share how you understand Conflict of Interest and how it relates to serving as a guardian or conservator.*
5. Self Assessment

Rate yourself in each category listed below. 5 = high, 1 = low

KGP seeks volunteers who are compassionate, caring and able to serve as personal advocates.
Act responsibly and appropriately to the needs of others.
- 1
- 2
- 3
- 4
- 5
Interact with people of differing background and opinion.
- 1
- 2
- 3
- 4
- 5
Interact with persons with intellectual and behavioral health conditions.
- 1
- 2
- 3
- 4
- 5
Please comment on your ratings.
KGP seeks volunteers who are dependable and keep commitments.
Personal integrity and honesty
- 1
- 2
- 3
- 4
- 5
Fulfill commitments in a timely manner
- 1
- 2
- 3
- 4
- 5
Complete reports/paperwork in a timely manner
- 1
- 2
- 3
- 4
- 5
Independent and assertive
- 1
- 2
- 3
- 4
- 5
Self-initiative
- 1
- 2
- 3
- 4
- 5
Work with limited supervision
- 1
- 2
- 3
- 4
- 5
Please comment on your ratings.
KGP seeks volunteers able to make wise and appropriate decisions regarding another person.
Willing to learn new information
- 1
- 2
- 3
- 4
- 5
Follow guidelines and procedures
- 1
- 2
- 3
- 4
- 5
Make well-reasoned decisions
- 1
- 2
- 3
- 4
- 5
Maintain accurate records/documentation
- 1
- 2
- 3
- 4
- 5
Please comment on your ratings.
KGP seeks volunteers able to make wise and appropriate decisions regarding another person’s financial affairs.
Manage finances
- 1
- 2
- 3
- 4
- 5
Pay bills in a timely manner
- 1
- 2
- 3
- 4
- 5
Maintain accurate financial records
- 1
- 2
- 3
- 4
- 5
Balance a checkbook/bank statements
- 1
- 2
- 3
- 4
- 5
Please comment on your ratings.
6. Personal and Financial Background
Have you ever been convicted of a crime other than a minor traffic offense? If yes, provide dates and specific information.*
Have you ever been involved with, charged and/or substantiated in a Department for Children and Families (DCF) investigation of abuse, neglect, or exploitation of a child or an adult? If yes, provide dates and specific information.*
Have you ever filed for bankruptcy? If yes, provide specific information including the type of bankruptcy, initial and/or discharge date, etc.*
Have you ever been subject to foreclosure, garnishments, debt collections or other judgments? If yes, provide dates and specific information.*
7. Background Checks

The KGP conducts criminal history and other background record checks to determine the appropriateness of a potential volunteer nominee to serve as a court appointed guardian or conservator. 1. The KGP requires a signed Release of Information (ROI) to access the Department for Children and Families Adult (DCF) Abuse Central (ANE) Registry and the DCF Child Abuse Registry. KGP also requires a signed (ROI) for a criminal background check. 2. A potential volunteer will receive the ROI's to sign and return to KGP allowing the KGP to conduct these background checks.
Affirmation
- I hereby affirm that all the answers provided on my Volunteer Information Form are true.
- I understand the information obtained through references and background checks will be confidential and for the exclusive use of the Kansas Guardianship Program.
- I acknowledge KGP will provide certain personal information to DCF, Kansas Department for Aging and Disabilities (KDADS) and the Court necessary to fulfill the statutory requirements for nomination of guardian or conservator.
- I understand if the criminal history and other background record checks reveal information different than my prior statements, it may affect my becoming a KGP volunteer.
By typing your name below, I verify the information provided herein to be true and accurate.*
References

Provide information for SIX people you have known for at least one year. DO NOT USE RELATIVES. References can include employers, professional contacts or friends. Please notify the listed references to expect contact from the Kansas Guardianship Program. Please print clearly and provide all information requested.
1. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*
2. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*
3. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*
4. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*
5. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*
6. Reference Name*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Relationship (friend, coworker)*
Length of Time Known*