HomeMy WebLinkAboutVolunteer Chaplain Application (Melhorn).pdfExhibit "A"
City of Winter Springs
Volunteer Application Form
Thank you for considering the City of Winter Springs as an opportunity for your volunteer
activity. Please provide the following information:
Your name:M 6 W VA
Choose one: Home Business ellul
Place checks in the following chart to indicate the periods of time which you currently have
available for volunteer activity:
Morning
Mid -Day
Afternoon
Evening
Monday
®%`
Tuesday
Ef
Wednesday
0
Thursday
Friday
Saturday
Sunday
El
For what volunteer position(s) are you applying? V01:4 0 t ter `; k GAS 1;',
What skills do you have, such as typing, use of a computer, artistic abilities, etc.?
L� Nt nTG ✓c 17 F ln1-1 y Y4
1
Are you under 18 years of age? n d If so, Date of Birth
Are you currently employed? z If yes, where? hLIn r 4 e14.._ 4_
Are you currently a student? i-d If yes, where?
Are you a City employee? no Department?
Are you a retired City employee? n? Department?
I am able to volunteer only until: (date)
rtease uescrme your areas of Interest ana aescrine
Ok"I tt/cs AO Wk
n:Otis, felt Svc of (,t/w
7�E-�(ui GG�o.,c,.s•�-� — ijl�rds .�� �y4n:st���
reiatea eaucarion or worx
Do you have any prior volunteer experience?
If yes, please describe:
Z Gnrf A5 (A/ e.,{W
3. Z. r'' S ' .nth., �"t �'✓`,w r t G �.,s n F ,�G�t s(L �'1
i
Are you under care of a medical professional for any physical or psychological treatment that may
affect your ability to safely and satisfactorily perform your volunteer duties?
ho
Have you ever been convicted of, or pled "nolo contendere" to, a felony? n
If yes, please explain:
I hereby certify that all statements made in connection with this application for volunteer work are
true to the best of my knowle e.
Signature Date: 1 A4A4s 7 a j
Print Name N �� e
1 hereby authorize the City of Winter Springs to obtain a record of my criminal convictions
(including but not limited to pleas of "nolo contendere ") from the Florida Department of Law
Enforcement or any other gency that collects records of criminal convictions.
Signature Date: ti n a h 2 U25
Print Name
Date:
Signature of Parent or Guardian (minors only)
Printed Name of Parent or Guardian (minors only)
Exhibit `B"
City of Winter Springs
Standard Volunteer Consent
I agree to read and abide by the policies relating to appropriate behavior and standards of
conduct to be displayed by the City volunteers. I acknowledge that, if at any time such policies are
amended, I will be provided the amended policies and at such time will be responsible for abiding
by any amended provisions of the policy in addition to those included in the original policy.
I further understand and agree to accept the responsibilities of the volunteer position and
participate in any training required by the City. I accept the guidance of my supervisor and shall
notify my supervisor of absences and incidents of injury. I acknowledge that I freely donate my time
without any expectation or promise of compensation. Lastly, I agree to abide by the following in
carrying out my duties and understand that a violation of any of the below statements may result in
my disqualification or termination:
1. I will keep confidential all information as required.
2. I will refrain from publishing any data gathered during the volunteer term and from
disseminating commercial advertisements, press releases, or opinions without prior
written consent of the Human Resources Coordinator.
3. I will refrain from any type of solicitation or charging, requesting or accepting any
fee, gift, reward or payment of any kind for my volunteer services.
4. I will refrain from offering medical and/or legal advice even though I may be asked
for such.
5. I will maintain a current driver's license and automobile liability insurance if driving
is required as part of my volunteer services.
6. I will report immediately any suspected incident of abuse to children, dependent
adults, or elders to appropriate authorities and the Human Resources Coordinator.
7. I agree to provide an update to the Human Resources Coordinator of any change to
the information I submitted on my application during the term of volunteer period.
8. I acknowledge that I have read and understand the "External Volunteer Policies"
attached hereto as Attachment "1 ", and will not engage in inappropriate and/or illegal
conduct or behavior including but not limited to harassment, discrimination, and/or
drug or alcoh ( abuse.
f.
Signature Date:
Print Name �� bGr ttie, /r
Date:
Signature of Parent or Guardian (minors only)
Printed Name of Parent or Guardian (minors only)
Your Name
Organization
Street Address
Exhibit "C"
City of Winter Springs
City Volunteer Enrollment
�\ fl t 6-4 me I L'%1
City r r.n Zip 3Z^7�
Telephone No. D -- 4 Choose One: Home Business ±llular
Date of Birth q 1 7 i'
Emergency Contact Name C .n� �� e 1�01A
Emergency Contact Phone____C�-%;Z-
Relationship
If your volunteer assignment will include driving or operating a vehicle, please provide the, following
information:
Driver's License: L1,4& t`�� s °7� 55-2 t �f _ Expiration Date: ') -"c f y `za3ZJ
Auto insurance company: �fi Selzo�o.
The following information will be completed by the Human Resources Coordinator:
Volunteer Assignment
Position:
Location:
Supervisor:_
Start Date
Background Check Required? Yes/No
Background Check Completion Date:
End Date
Vehicle Required? Yes/No Type:
Exhibit "D"
City of Winter Springs
City Volunteer Release of Liability
In accepting a position as a volunteer with the City of Winter Springs, I agree to accept voluntary
Workers' Compensation coverage as the sole and exclusive remedy for any injuries I might sustain
while in such volunteer service. Such voluntary Workers' Compensation coverage will be in effect
to pay for medical attention for actual injuries sustained during volunteer service subject to
Workers' Compensation statutes and regulations. Since volunteer service does not include wages,
such compensation does not provide for same.
HOLD HARMLESS AGREEMENT: I agree to hold the City of Winter Springs harmless for any
such injuries and agree not to pursue legal proceedings against the City for any reason associated
with voluntary servi except through the Workers' Compensation Act.
�i
.5
Signature of Volunteer Date '
Print Name of Volunteer