Have You Ever Been Convicted of Any Crime? Yes No

CITY OF HENDERSON VOLUNTEER CONNECTION APPLICATION FORM Name (Last, First, Middle) Primary Phone

Street Address, City, State and Zip Code Secondary Phone

E-mail Address

Emergency Contact (name, relationship, phone number)

Have you ever been convicted of any crime? Yes No If yes, please explain, in detail, the nature of the offense, date of conviction, location, and disposition (i.e. paid fine, time served, etc.), and the conditions of any parole/probation, if applicable. DUI, reduction of DUI, reckless and careless driving convictions MUST be included.

Demographics You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of Birth (month, day, year) Gender  Male  Female Education Age Group  High School  15 and under  Trade/Vocational School  16 – 17  Some College  18 – 24  Associate Degree  25 – 34  College Degree  35 – 44  Masters Degree  45 – 54  Doctoral Degree  55 – 64  65 +

Skills & Experience Please summarize your skills and previous experience as they relate to the volunteer opportunities you are interested in. Date Organization Responsibilities

Availability

Area of Interest Department: Available Volunteer Opportunity:

Are you a current City of Henderson Employee? Yes No Please Complete Both Sides of Application CITY OF HENDERSON VOLUNTEER CONNECTION APPLICATION FORM If yes, please provide title and department. ______

Informed Consent, Release and Conditions

I understand and agree that submitting this application form does not automatically register me as a City of Henderson volunteer, and that there may be additional qualifications I must meet, including a background check and the acceptance of established volunteer policies and procedures.

As a volunteer for the City of Henderson I agree to: observe the policies and procedures of the City and the Department to which I may be assigned; participate in initial training as well as any additional training related to my services; notify immediate supervisor when sick and/or otherwise unable to serve as a volunteer; perform duties as outlined by the volunteer coordinator; dress in business attire suitable to the assigned tasks; and immediately notify my supervisor upon my being charged with any crime.

I hereby certify that all statements made in this volunteer service form are true. I acknowledge that any false statement, omission or misrepresentation on this form will be cause for refusal of placement or immediate cessation of my volunteer service at any time during the period of my placement. I understand that I am servicing at all times on a voluntary basis without promise, expectation, or receipt of compensation for my services. I understand that that this agreement can be cancelled at any time by either myself or the City of Henderson.

I offer to volunteer my services to the City of Henderson. I realize that I will not be compensated in any way (including cash, privileges, benefits or future employment). I understand that the Department and/or I can cancel this agreement at any time. I release the City of Henderson, its employees, agents, leaders, instructors, contractors, and volunteers from any liability for loss or injury to my person or property which might occur due to negligence or other acts or omissions. This release applies to any losses or injuries which may occur as a result of, or during my participation in, volunteer service. I realize that this release is a binding contract. I have read and understand this release. I knowingly and voluntarily sign below. The City may use my photograph for any official Department publications and/or productions.

I fully understand, acknowledge and agree to the following conditions: The City of Henderson reserves the right to make the final decision on placement of volunteers. Background checks, review of current dated and provided motor vehicle records (if applicable) in accordance with City policy, will be conducted on applicants. All statements made in this form are true and authorization is given to investigate all matters contained in this form. I authorize the City of Henderson to receive any criminal history information that may be contained in the files of any national, state, or local criminal justice agency. Any false statements or misrepresentations on this form will be cause for refusal of placement or immediate cessation of my services at any time during the period of my placement. I understand that the volunteer program does not qualify me for paid employment with the City of Henderson, and as a volunteer, I will not be entitled to any employee benefits, with the possible exception of workers compensation benefits, if applicable, and only to the extent provided by law.

Volunteer Signature Date

Signature of Parent/Guardian if volunteer is a minor

Thank You for Your Interest in The Volunteer Connection Department of Human Resources – Jennifer Fennema, Director 240 Water Street, Henderson, NV 89015 - Phone: (702) 267-1900

HRAD-0010 Admin Rev. (04/15)