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

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.

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.