Name: __________________ ________________ Today’s Date:__ __/__ __/__ __ __ __
Last
First
Month
Day
Year
GENERAL INFORMATION
Current Address: _________________________________
Date of Birth: __ __/ __ __/ __ __ __ __
City: _____________________
State/Zip: _______________
Alt. Phone: ________________
Church: ___________________ ☐ Cell ☐ Home ☐ Work (Please Check)
E-Mail:___________________________
Primary Phone: ______________
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:
- Weekday mornings or afternoons
Academics
- Weekday evenings (6-8:30pm) and/or Saturdays (10am-12pm or 2-4pm)
Athletics
- Tuesday (6-9pm) and/or Thursday (3:30-9:00pm)
Performing Arts
Summer Day Camp - Monday thru Friday (June – August)
- Monday (6-9pm, June-August)
Monday Nights
Marathon
Football Clinic
Athletics Banquets
Concerts & Performances
Special Events
(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
2. one day a week
3. ongoing program
weekday evenings
less than one day a week
special events
1
weekends
more than one day a week
UIF VOLUNTEER RELEASE AND WAIVER OF LIABILITY
PLEASE READ CAREFULLY
I,
under the following terms:
, the volunteer, herby freely and voluntarily, without duress, execute this Release
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
2
If checking ‘Box 1,’ please submit a copy of your ‘DeclaraƟon Page’ of auto
insurance coverage to Urban Impact at your earliest convenience
3
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 Fingerprinting o 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 8 of this application, in lieu of completing the fingerprinting requirement. If you have not lived in Pennsylvania 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 be permitted to volunteer until all required clearances have been brought into compliance. 
Prospective volunteers who have recently had background checks run, whether FBI Fingerprinting, PA Criminal, or PA Child Abuse, are welcome to furnish and submit a copy of any of these clearances to Urban Impact 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 to Conduct a Background Investigation. Failure to disclose a past conviction of any nature will result in the rejection of a prospective volunteer.  Applicants disclosing a past conviction are required to meet directly with Urban Impact prior to being cleared 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 any circumstance: Crimes against children, murder, armed robbery, and rape. All violations not listed here are subject to both Act 153 and Urban Impact’s volunteer violation guidelines, and may require the completion of 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 incurred by Urban Impact to run their background check clearances. On average it costs upwards of $40 to run all state and organizational required clearances on a new volunteer applicant. Any donation received allows us to dedicate 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) (Print Name) (Today’s Date) 5
_______________________
____________________________
__________________________________
__________________________________
______ / ______ / _________
_________________________________
___________________________
________ — ______ — __________
_______________
______________
_____
_____
_______
___________________________
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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:
x the position I am applying for is unpaid; and
x I 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
Section 2702
Section 2709
Section 2901
Section 2902
Section 3121
Section 3122.1
Section 3123
Section 3124.1
Section 3125
Section 3126
Section 3127
Section 4302
Section 4303
Section 4304
Section 4305
Section 5902(b)
Section 5903(c) (d)
Section 6301
Section 6312
(relating to criminal homicide)
(relating to aggravated assault)
(relating to stalking)
(relating to kidnapping)
(relating to unlawful restraint)
(relating to rape)
(relating to statutory sexual assault)
(relating to involuntary deviate sexual intercourse)
(relating to sexual assault)
(relating to aggravated indecent assault)
(relating to indecent assault)
(relating to indecent exposure)
(relating to incest)
(relating to concealing death of child)
(relating to endangering welfare of children)
(relating to dealing in infant children)
(relating to prostitution and related offenses)
(relating to obscene and other sexual material and performances)
(relating to corruption of minors)
(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 Child Abuse Clearance, as the turnaround time for online applicants is weeks faster than when processed by mail. 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 – [email protected] or 412‐321‐3811 x107 ‐ EDUCATION: Laura Maffeo – [email protected] or 412‐321‐3811 x113 ‐ PERFORMING ARTS: Kim Tryon – [email protected] 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 [email protected] 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 Jesus
Christ. 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: [email protected]
EDUCATION: [email protected]
PERFORMING ARTS: [email protected]
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