Please complete this application by pen (print) or typewriter in its entirety. PERSONAL INFORMATION. First MI Last. Street City State Zip
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1 Qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, covered veteran's status, marital status, or the presence of a non-job-related medical condition or disability. City of Suffolk Volunteer Application Suffolk Parks and Recreation 134 South Sixth Street P.O. Box 1858 Suffolk, Virginia (757) Fax (757) Please complete this application by pen (print) or typewriter in its entirety. POSITION APPLIED FOR: PERSONAL INFORMATION NAME: ADDRESS: PHONE: First MI Last Street City State Zip Daytime Evening Alternate ADDRESS: Which area(s) would you be interested in volunteering? Economic Development Finance Health Department Human Resources Library Parks & Recreation Planning/Community Dev. Public Safety Public Utilities Public Works Social Services Tourism Other: Have you been convicted of a felony within the last 7 years? Yes No If yes, please explain: Are you required to complete community service to fulfill a court order? Yes No If yes, please explain: How did you hear about our Volunteer Program? What would you like to achieve by volunteering with the City of Suffolk? 1
2 Using the space below, please indicate the hours that you would be available: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Please list any additional notes regarding availability: Would you be willing to volunteer for multiple events? Yes No EDUCATION AND TRAINING Please circle the highest grade completed: Higher Name of High School: City/State/Zip: If you did not complete high school, do you have a high school equivalency diploma (GED)? Yes No Name of College: City/State/Zip: List all degrees and major course(s) of study: Check the following skills, experiences, and knowledge that you have: Word Processing: Computers: Calculator/Adding Machine: Typing WPM List any additional skills, abilities, and/or knowledge: List any courses which you have taken that are related to the position you are applying for: List any valid certifications and/or licenses (Driver's License, CPR, Lifeguard, etc): 2
3 EXPERIENCE List and describe your current and/or past work experiences. Volunteer work is acceptable. Use additional sheet if necessary. Employer Job Title Address City State Zip Phone Supervisor Dates of Employment Job Duties and Responsibilities: Employer Job Title Address City State Zip Phone Supervisor Dates of Employment Job Duties and Responsibilities: Employer Job Title Address City State Zip Phone Supervisor Dates of Employment Job Duties and Responsibilities: 3
4 Have you ever been employed by or volunteered with the City of Suffolk? Dates of Employment Department(s) Positions REFERENCES Please list at least two references who are not related to you: Name Phone Relationship Name Phone Relationship Name Phone Relationship AGREEMENT I certify that answers given herein are true and complete to the best of my knowledge without consequential omission of any kind whatsoever. I agree that the City of Suffolk shall not be liable in any respect if I am disqualified from volunteering because of the falsity of statements, answers or omissions made by me in this application. I consent to any substance abuse and/or criminal background investigation which may be required for the position for which I am applying. Consent to use Photographs I understand that photographs may be taken of me at any City of Suffolk program or facility for publication in material used to promote the City of Suffolk, it s programs, or events. Waiver and Release In consideration of being permitted to participate in any way as a volunteer of the City of Suffolk, I for myself, my heirs, personal representatives or assigns, do hereby release, waive, and forever discharge the City of Suffolk, its Council members, officers, employees and agents for liability from any and all claims, demands, rights and causes of action of whatever kind resulting in, but not limited to, bodily injury, personal injury, accident or illness (including death), and property damage sustained by me, my agents, employees, or family members arising from participation as a volunteer for the City of Suffolk. Indemnification I shall indemnify and hold harmless the City of Suffolk, its Council members, officers, employees and agents from and against any and all claims, losses, damages, fines, penalties, suits and costs, including injury and death penalties imposed by any authority which arise out of any violation of law by, and all acts and omissions caused by me, my employees, subcontractors, agents, or representatives while participating as a volunteer for the City of Suffolk. Signature of Applicant: Date: Signature of Parent: (If applicant is under the age of 18) Date: 4
5 NAME: VOLUNTEER APPLICATION APPENDIX Please check any volunteer assignments in which you would be willing to participate. Public Service Volunteer Outreach Volunteer Technology Volunteer Grounds Volunteer Gain hands-on experience working with the public, shelving materials, assisting staff with collection maintenance and displays. Assist the Outreach Services Department and Friends of the Suffolk Public Library at community events, Bookmobile stops, and other outreach programs. Troubleshoot computer issues for the public in library computer labs and assist staff with technology instruction. Help maintain branch aesthetics by helping maintain building exteriors. Teen Advisory Board (Teens Only) Assist with the implementation of and participate in SPL teen programming and serve as a public service volunteer ADDITIONAL QUESTIONS: Are your volunteer hours required for a class or school? YES NO If YES, total hours needed: Deadline for completion: Library branch preference: Chuckatuck Library (5881 Godwin Boulevard) Morgan Memorial Library (443 W. Washington Street) North Suffolk Library (2000 Bennetts Creek Park Road) Do you have any physical or medical conditions (allergies, etc.) of which we should be aware? If yes, please list. In case of an emergency, please contact (include name, relationship, number where they can be reached night and day, and address if available):
6 VOLUNTEER IN YOUTH SPORTS Consent/Release Form NYSCA Chapter ID# 1617 Name of Organization Suffolk Parks & Recreation Applicant s Name (printed) Date of Birth Social Security Number Applicant s Address City State Zip I,, authorize and give consent for the above named Name of Applicant organization to obtain information regarding myself. This includes the following: Employment records/ Employers references Criminal background records/information Criminal background check/fingerprint Driver s license check Automobile insurance check Training/experience Personal references Addresses I the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my volunteer application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization s guidelines. Print Name: Date: Signature:
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