SCREENING GUIDE FOR NEW 4-H VOLUNTEERS

SCREENING GUIDE FOR NEW 4-H VOLUNTEERS There are 3 steps to becoming a 4-H volunteer. We have online and paper options for each step. Step A: Application ONLINE: http://www.extension.umn.edu/youth/mn4-h/volunteer/ Become a Volunteer tab Application link Fill out, print and add signature PAPER: Available at your county office An original, ink signature is legally REQUIRED on all applications. We cannot accept emailed or faxed applications. Step B: Background Check ONLINE: http://www.extension.umn.edu/youth/mn4-h/volunteer/ Become a Volunteer tab See online instructions link Submit online link OR print Background Check Release and fax/mail PAPER: Background Check Release available at your county office Fax or mail to The McDowell Agency (address on the release form) Please choose either online OR paper, not both, so we don t incur duplicate costs! Step C: See the Orientation ONLINE: http://www.extension.umn.edu/youth/mn4-h/volunteer/ Become a Volunteer tab Watch videos or Read PDF link Submit the Orientation Report Form PAPER/DVD: Available at your county office, along with the Orientation Reporting Form Please allow 2-3 weeks for your application materials to be processed. You will be notified when your screening is complete. You must wait for approval BEFORE beginning to serve as a volunteer, or you put yourself and Minnesota 4-H at risk. Revised August 2017

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(Office use only) Date Received: Year Screened: Screened Restricted Household Inactive Application for New 4-H Volunteers (Screening Step A) DAKOTA 4-H County: Email: For Otter Tail County, please indicate East or West. For St. Louis County, please indicate North, South or Incredible Exchange. For American Indian programs, please write the tribe name as the county. First Name: Middle Name: Last Name: Mailing Address: City: State: Zip Code: Gender: Male Female Primary Phone: Cell Phone: Accept text messages Cell Company: Work Phone: Work Extension: Emergency Contact: Name: Primary Phone: Alternate Phone: Relationship: Hispanic Ethnicity (check one): Hispanic or Latino OR Not Hispanic or Latino Racial Groups (check all that apply): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander Prefer not to state Residence (check one): Farm Town < 10,000 and rural non-farm Town/city 10,000-50,000 and suburbs Suburb of city > 50,000 Central city > 50,000 Does anyone in your family serve in the military? (check if yes) Parent Sibling Son/Daughter Self/Spouse Branch: Component: Active Duty National Guard Reserves (Air Force, Army, Coast Guard, DOD Civilian, Marines, Navy) Were you in 4-H as a youth? Yes No If yes, list projects/areas involved: Year of birth: Please select the highest education level in your household: Unknown Partial high school High school graduate or GED certificate Some college, incl. vocational/technical College (2-4 year degree completion) Graduate/professional training I prefer not to provide this information Have you been a 4-H volunteer before? Yes No If yes, list County/State: Number of years as 4-H volunteer: Role(s) held: In what way(s) would you like to volunteer with 4-H? (Ex. leading/ working with a club, group or project, chaperoning) Check here if you would like to talk further with 4-H staff about volunteer roles or opportunities. Volunteer Screening Application Page 1 of 6 Revised September 2017

Current Occupation: How long have you worked at that position? Previous Work Experience: Educational Degrees Held: Special Training Received: Past volunteer experience (type of organization, role played, number of years, etc.): Other interests, hobbies or skills that may contribute to 4-H youth development work: Which would you prefer to work with? Youth Adults Either/Both If you prefer to work directly with youth, what grade level(s) do you prefer? (Check all that apply) Grades K-2 Grades 3-5 Grades 6-8 Grades 9+ Health Information: Please be accurate yet concise. In the event of an emergency, this may be the only immediate source of information. Do you have a health diagnosis that is important for program staff to know in order to maximize participation and ensure safety and well-being? Health diagnosis details/explanations and suggested accommodations. No, I do not have any relevant health diagnosis. Yes, I have a physical disability, a learning disability, behavioral disorder, and/or mental health diagnosis. Do you have any specific dietary needs? No special food needs or requests. Yes, food allergies or restrictions (e.g. peanuts, gluten-free) or food preferences (e.g. vegetarian) or religious restrictions. Dietary needs details/explanation. Do you have any allergies or reactions to drugs or things in nature? No Yes Describe allergies or reactions. Do you have any conditions requiring medication that program staff should be aware of to help ensure your safety (e.g. use of inhaler, epipen)? No medication needs to be brought to the program staff attention. Yes, staff should be aware of the medication(s) I take. If YES, please provide details in the box directly below. Medication details/explanation including condition(s) requiring medication, name of medication(s) and any possible assistance that may be needed with monitoring or administering. Is your Tetanus immunization current? No Yes Not sure Date of last Tetanus shot (month/year). Leave blank if not current or unknown Do you have any other health conditions? No Yes Describe other health conditions. Volunteer Screening Application Page 2 of 6

Volunteer Name DAKOTA County Primary Club or Group: Check 4-H Projects that would interest you as a volunteer: Aerospace Aquatic Robotics Beef Bicycle Cat Child & Family Development Citizenship Clothing & Textiles Cloverbuds (Grades K-2) Computers Consumer Education Crafts & Fine Arts Crop Sciences Dairy Dog Electric Engineering Design Entomology Exploring Animals Exploring the Environment Fishing Sports Flower Gardening Food & Nutrition Food Preservation Forest Resources Fruit Geology Global Connections Goat Dairy Goat Meat Health Home Environment Horse Horse Training Horseless Horse Indoor Gardening Lama (llamas and alpacas) Lawn & Landscape Design Needle Arts Performing Arts Pets Photography Plant & Soil Science Potatoes Poultry (and pigeons) Quilting Rabbits (and guinea pigs) Robotics Safety Self-Determined Sheep Shooting Sports & Wildlife Shop (wood and/or metal) Small Engines Swine Tractor Vegetable Gardening Veterinary Science Video Water/Wetlands Wildlife Biology Youth Leadership 4-H Activities/Groups vary by county and region; talk with your 4-H program staff about opportunities. Code of Conduct Introduction The University of Minnesota Extension 4-H Youth Development program (Minnesota 4-H) builds engaged young people who are able to learn and lead in a global society, educates adults to work effectively with youth, and partners with communities to create supportive social environments that help youth thrive. A standard of behavior for all individuals involved in our program is one of the key components for creating a welcoming learning environment that is physically and emotionally safe. Any individual participating and/or volunteering with the Minnesota 4-H program at any level (individual, club, county, regional, state, national and international) is subject to the behavior standards and rules governing participation and involvement as outlined in the Minnesota 4-H Code of Conduct. In addition to the Minnesota 4-H Code of Conduct, there may be additional policies, rules, and procedures relating to specific 4-H events and activities that will also apply to those events/activities. The Minnesota 4-H Code of Conduct applies to both face-to-face and online environments and will be enforced with 4-H members, 4-H parents and 4-H volunteers as follows: While participating in or attending a 4-H sponsored program (e.g. club meeting, project meeting, activity, event, learning opportunity). At the county fair while participating in or attending a 4-H event or while on premises used for 4-H purposes (e.g. show ring, exhibit building, barn, food stand). Volunteer Screening Application Page 3 of 6

At the state fair, during their (or their child s) assigned encampment or assigned volunteer responsibility. In addition, the Minnesota 4-H Code of Conduct applies and will be enforced as follows: At all times during the year of service for 4-H members who agree to represent Minnesota 4-H to the public by accepting a statewide 4-H leadership role (e.g. state 4-H ambassador, state 4-H PDC member). At all times throughout a volunteer s service when behavior outside of Minnesota 4-H puts youth at risk or has the potential to put youth at risk. The opportunity to participate in and/or volunteer with Minnesota 4-H is a privilege and honor, not a right. All youth participants, parents/guardians supporting their child s participation in 4-H, and volunteers are expected to sign the Minnesota 4-H Code of Conduct before becoming involved with Minnesota 4-H. Continued participation in Minnesota 4-H is based on individuals meeting the requirements of the program including the Minnesota 4-H Code of Conduct. Infractions to the Minnesota 4-H Code of Conduct will be addressed and may result in consequences. Because Minnesota 4-H is a safe place for youth and adults to learn from their mistakes, minor disruptive or inappropriate behavior will first be addressed through redirection and coaching. When the nature of the offense is more severe or there is a pattern of minor disruptive or inappropriate behavior, violations of the Minnesota 4-H Code of Conduct will result in consequences. The consequences may range from a verbal warning to the loss of privileges (e.g. participation at the event or future events, forfeiture of awards or other forms of recognition, forfeiture of positions of leadership, limitation on volunteer responsibilities) to full removal from Minnesota 4-H. Consequences may be applied to entire 4-H entities, when applicable. Code of Conduct for Volunteers 1. I understand that Minnesota 4-H is a non-formal education program in which I have an option to volunteer. I will complete the expectations of my volunteer assignment, working with staff and volunteers to create quality learning environments for youth. I accept my responsibility to engage in program activities and to excuse myself from this volunteer assignment if it does not meet my volunteer objectives. I recognize the organization has the responsibility and authority to remove individuals who are serving as volunteers that are disruptive to Minnesota 4-H or for any other reason Minnesota 4-H deems appropriate. 2. I accept my responsibility to represent Minnesota 4-H by holding myself to the standards of the 4-H pledge and motto. I will refrain from behavior that negatively represents myself, my family, my community, 4-H or the University of Minnesota. 3. I acknowledge that the 4-H program utilizes competition related to project work as a tool for learning. I will demonstrate good sportsmanship, encourage this behavior in program participants and other volunteers, and not allow this behavior to detract from the learning experience. I will not let my personal desire to win overshadow the needs of the group or violate positive youth development principles. 4. I accept my personal responsibility to be informed and follow the policies, rules and deadlines established by Minnesota 4-H. I will not cheat, lie, knowingly furnish false information, deceive, or otherwise engage in dishonest, unethical or illegal behaviors. I will not encourage others to disregard or intentionally violate conditions of Minnesota 4-H participation. 5. I will act in a respectful and responsible manner during all 4-H programs. I will comply with directions of 4-H officials acting in the performance of their duties. I will not obstruct or disrupt any 4-H program or encourage others to engage in such conduct. I understand that a judge s decision is final. 6. I will promote a spirit of inclusion and welcome participation of individuals from all backgrounds. I will encourage youth involvement in decision making. I will practice fair-mindedness by being open to ideas and opinions of others. I will comply with equal opportunity and anti-discrimination laws. I will not participate in behaviors that discriminate against other people. 7. I will communicate (oral, written and electronic) in an open, honest, respectful manner in all situations involving the 4-H program. I will refrain from communication that is negative, offensive, destructive or hurtful to others. I will refrain from sharing private matters in a public group setting. I will not engage in or tolerate slander, put-downs, insults, taunting, name-calling, yelling, profane language, sexual innuendos and other comments or hostile behaviors likely to offend, hurt or set a bad example. If I witness this type of behavior, I will contact the staff member. If the situation is escalating to where I feel unsafe, I will contact the authorities. 8. I will ensure a safe environment for myself and others involved in 4-H programs that I am leading, implementing Minnesota 4-H risk management practices. I will not act in an irresponsible or potentially hazardous manner. I will access and operate machinery, vehicles and other equipment in compliance with laws, rules of the 4-H program, and general safety practices. 9. I will model healthy choices. I will not offer alcohol, tobacco products or illegal substances to youth. I will not possess or use illegal substances. I will not use alcohol or tobacco products during a 4-H program. I will not attend 4-H programs under the influence of alcohol or any illegal substance. Volunteer Screening Application Page 4 of 6

Volunteer Name DAKOTA County 10. I will be courteous and respectful of other individuals and their property. I will dress in a manner that is appropriate, tasteful and respectful for youth. I will not use, abuse or take another individual s personal belongings. I will not damage facilities. 11. I will abide by the University of Minnesota policy on the safety of minors. I will not have sexual contact or a sexual relationship with a member. I will not use physical punishment for discipline. If I have reason to believe that a member is being neglected or physically or sexually abused, I will make an immediate report of the neglect or abuse to a law enforcement or social service agency. 12. I will abide by the University of Minnesota policy on possession and carrying of weapons (firearms and other dangerous weapons as defined by Minnesota law.) I will not possess or carry a weapon while on University property or during attendance at a 4-H program, regardless of location, except in the following two circumstances: (1) I am lawfully storing a firearm inside a personal motor vehicle, or (2) I have been authorized by the 4-H program to possess and carry firearms at 4-H Shooting Sports/Wildlife programs. 13. I will use appropriate channels within Minnesota 4-H to address concerns and conflicts, working towards resolution. I will accept the decision of the individual and/or group that has the leadership and authority to make the decision, even if the decision is not the one I personally desire. 14. I will demonstrate behaviors appropriate as a positive role model. If I have a guest or guests in attendance at a 4-H program, I will encourage them to abide by the Minnesota 4-H Code of Conduct and ask them to leave if they are unable to abide by the code. I recognize that if the guest s behavior interferes with the learning, my guests may be asked to leave the 4-H program. 15. I will expect youth and adults participating in the programs I lead as a 4-H volunteer to follow the Minnesota 4-H Code of Conduct. If behaviors contrary to the Minnesota 4-H Code of Conduct are demonstrated during a 4-H program, I will address the situation appropriately and consult with my staff supervisor when needed. Volunteer Acknowledgements Code of Conduct Release I have read, accept, and will abide by the full University of Minnesota Extension 4-H Youth Development (Minnesota 4-H) Code of Conduct for Volunteers including the introduction and the statements describing expected behavior. I understand that the expectations apply throughout Minnesota 4-H. I also understand that infractions of the Minnesota 4-H Code of Conduct will result in consequences and that these consequences apply throughout Minnesota 4-H. I will accept the consequences determined by Minnesota 4-H. Media Release I give permission to Minnesota 4-H and its employees or representatives to take photographs, video, or audio footage of me and/or, my property for use in any media format, now or hereafter known for future educational programs to help promote 4-H. I release to Minnesota 4-H all rights to exhibit this work publicly or privately in an educational/promotional format without compensation or additional consideration. NOTE: For information about opting out of the photo release, contact your local Extension staff: www.4-h.umn.edu/county. Medical Authorization I authorize each of the following: (a) the health history and medical information I have provided is correct. I understand that it is my responsibility to provide updates (including changes in health conditions, medical coverage, or activity restrictions) throughout the program year and prior to any events/activities in which I intend to participate; (b) if an injury or other medical condition occurs or arises, I grant permission for medical treatment to be obtained and authorize the physician and/or the other medical staff to employ such diagnostic procedures and medical treatment as deemed necessary; c) I authorize the release of any medical records necessary for treatment, referral, billing, or insurance purposes; and (d) I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians and/or health care unit, beyond the amount covered by 4-H accident insurance. Volunteer Screening Application Page 5 of 6

Screening Release I understand that some of the above information is considered private under the Minnesota Government Data Practices Act, Chapter 13. This information will be used for programming purposes and given to people responsible for each program. I authorize the University of Minnesota Extension and/or their agents to investigate my background as it pertains to volunteer considerations. This may include investigation of information contained in public records including criminal and motor vehicle data. In signing below, I agree to complete a background check following the instructions provided for me, and I consent to be rescreened on a regular basis (typically every 3 years). I release all persons, companies, or organizations furnishing such information from liability and responsibility. This authorization does not expire, will include rescreening on a regular basis, and will be considered revoked only upon my written authorization or request to the University of Minnesota Extension. A copy of this document may be substituted for the original. The background check includes criminal background information and does NOT include a credit check. The background check is for use only by the University of Minnesota Extension 4-H organization, is defined by the needs and requirements of 4-H, and is applied consistently to all volunteer applicants. Under no circumstances will the information collected and maintained by the McDowell Agency, Inc. ever be sold or provided to an outside entity for any purpose. For more information about the McDowell Agency s privacy policies, visit www.mcdowellagency.com/faq.php. I certify that the information in this application is true and current. I understand that misrepresentation or omission of facts requested is cause for non-acceptance as a University of Minnesota Extension volunteer. I further understand that the University of Minnesota Extension is not obligated to accept or place me as a volunteer. If accepted as a volunteer, I agree to abide by the expectations of the University of Minnesota Extension and to fulfill my volunteer responsibilities to the best of my ability and in a manner consistent with the mission of the University of Minnesota Extension and the Minnesota 4-H Program. I am obligated to immediately report any criminal changes that may occur following the signing of this document or immediately request Minnesota 4-H to revoke my privilege of serving as a 4-H Volunteer. I have reviewed the Volunteer Screening Release and authorize the University of Minnesota Extension and/or their agents to conduct a background check as it pertains to my volunteer considerations. VOLUNTEER NAME (Printed) VOLUNTEER SIGNATURE DATE AN ORIGINAL INK SIGNATURE IS REQUIRED ON THE APPLICATION. We legally cannot accept scanned, emailed or faxed signatures. PLEASE RETURN THIS APPLICATION TO: Dakota County 4-H Attn: Volunteer Coordinator 4100 220th St. West, Suite 101 Farmington, MN 55024 Acceptance as a 4-H volunteer is based on evaluation of your application, background check, and orientation. Staff will work with you to match your skills and interests to roles within the 4-H program, and training will be provided periodically. Have you completed the Background Check and Orientation? ALL 3 STEPS ARE REQUIRED BEFORE YOU BEGIN SERVING AS A 4-H VOLUNTEER. YOU WILL BE NOTIFIED WHEN YOU ARE ACCEPTED AS A VOLUNTEER. Volunteer Screening Application Page 6 of 6 Revised September 2017 The University of Minnesota Extension is an equal opportunity educator and employer.

Online Background Check Short Instructions (Screening Step B) 1) Go to www.mcdowellagency.com* and click on Client Log-in (in green menu bar at top). *This website works with all browsers. Try a different browser if the first one doesn t work. 2) Enter your User ID and Password (both are case sensitive): USER ID = 4HHHH9 PASSWORD = 4HHHH9 Then click the green Login button. 3) Select the request tab from menu that stretches across the top of the page. 4) Type your full name into the space next to Electronic Signature AND mark the box next to My name entered above signifies my electronic signature. 5) Click on Continue to proceed. 6) Enter the following Demographic Information: a) Last Name b) First Name c) Current Address d) Zip (City and State will be automatically filled in after entering your zip code) e) Date of Birth f) Social Security Number* *If you receive a message about a duplicate entry, you already have a background check in the system. Contact your county or regional staff with questions. 7) Scroll down to the Additional Information section, and enter the following: a) In the Reference field, enter the name of the county or tribe where you wish to volunteer (which may be different than the county where you live). For Ottertail County, please indicate East or West. For St. Louis County, please indicate North, South or Incredible Exchange. b) If you have been convicted of a crime, list the date, offense, county and state of each incident under Special Research Instructions. 8) Click the Continue button. 9) Under Order Authorization and Submission, click on Agree and Submit Order. 10) You should see a Thank You page confirming your order. You may log out. Thank you!! (You have the option to print a copy for your records if you like.) Contact The McDowell Agency, our screening vendor, with any questions about the website: Office: 651-644-3880 or Toll Free: 877-644-3880 Email: anna@mcdowellagency.com 1101 Snelling Avenue North St. Paul, MN 55108-2705 Fax: 651-644-3877 Revised August 2017

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Background Check Release (Screening Step B) Complete only if NOT doing the online background check. Please Print Legibly Legal Name: First Middle Last Date of Birth: / / Gender: M / F Social Security Number: - - (required) County for which you are volunteering in 4-H: For Otter Tail County, please indicate East or West. For St. Louis County, please indicate North, South or Incredible Exchange. Please list all addresses for the past seven (7) years (attach additional sheets if necessary): Current Home Address: Street Apt City County State Zip Code Past Home Address: Street Apt City County State Zip Code Past Home Address: Street Apt City County State Zip Code Past Home Address: Street Apt City County State Zip Code List any other names you have used (attach additional sheets if necessary): - Name Dates Used City State - Name Dates Used City State Revised August 2017 Page 2 must be signed

Have you ever been convicted of a crime? Yes / No If yes, please complete next section (attach additional sheets if necessary): Date Offense City County State Date Offense City County State I authorize all persons, schools, companies, corporations, state agencies, federal agencies, and law enforcement agencies to release information without restriction or qualification to 4-H or The McDowell Agency, Inc. I hereby release 4-H and The McDowell Agency, Inc. from any liability arising from the preparation of this report or investigation relating thereto to the extent permitted by law. I agree that failure to reveal any requested information, or the giving of any false or misleading information on this form or any application form, may be grounds for refusal to enlist my services and negate any present or future volunteer or employment possibilities with this organization. Furthermore, I understand that any offer that has been made to me for the use of my volunteer services with 4-H is contingent upon full disclosure of requested information and subject to personal reference checks. I understand that the results of said background check may disqualify me from volunteering at 4-H and that any offer I have received is contingent upon this report and may be rescinded at any time as a result of findings deemed essential by 4-H. I understand that this release is valid for the duration of my service at and that 4-H or The McDowell Agency, Inc. (at the request of 4-H) may choose to investigate my background at any time during the term of my service. The background check includes criminal background information and does NOT include a credit check. The background check is for use only by the University of Minnesota Extension 4-H organization; the check has been defined by the needs and requirements of 4-H and is applied consistently to all volunteer applicants. Under no circumstances will the information collected and maintained by the McDowell Agency, Inc. ever be sold or provided to an outside entity for any purpose. For more information about the McDowell Agency s privacy policies, visit www.mcdowellagency.com/resources/frequently-asked-questions. I have read and understand the terms of this authorization and agree to the terms stated herein. A photocopy or facsimile of this authorization will be treated the same as an original. Signed Date Please do NOT submit this form to your 4-H program staff! Mail or fax this form directly to The McDowell Agency, Inc.: 1101 Snelling Avenue North, St. Paul, Minnesota 55108-2705 Fax: (651) 644-3877 If you have any questions you can contact The McDowell Agency: Office: 651-644-3880 Toll Free: 877-644-3880 Email: anna@mcdowellagency.com

Orientation Reporting Form (Screening Step C) Name: Address: Street City State Zip Preferred Phone Number: Email Address: COUNTY in which I plan to volunteer: For Otter Tail County, please indicate East or West. For St. Louis County, please indicate North, South or Incredible Exchange. How did you complete the orientation? Web/Online Print/PDF DVD As a result of the orientation and training session Please choose one response for each row: I have a better understanding of the mission of Minnesota 4-H. I have a better understanding of the relationship between Minnesota 4-H and the University of Minnesota. I learned more about the role of a 4-H volunteer. I know the stewardship and risk management practices for 4-H youth and volunteers. I know where to access resources to support the various volunteer roles. Agree Somewhat Agree Neutral Somewhat Disagree Disagree What future trainings would help you be a better volunteer in the 4-H program? I have read and understand the University s Safety of Minors policy. I have completed the Safety of Minors training and understand my responsibility to report abuse and neglect, and I will follow the appropriate procedures for reporting should such a situation arise. THIS BOX MUST BE CHECKED AND YOUR SIGNATURE ADDED IN ORDER TO BECOME A 4-H VOLUNTEER. Signature: Date: Please return your completed form to: Dakota County 4-H, Attn: Volunteer Coordinator, 4100 220th St. West, Suite 101, Farmington, MN 55024. University of Minnesota Extension is an equal opportunity educator and employer. In accordance with the Americans with Disabilities Act, this publication/material is available in alternative formats upon request. Direct requests to 218-828-2276. Revised August 2017