Peoria PlayHouse Children s Museum Volunteer Application Thank you for your interest in volunteering at the PlayHouse Children s Museum! Volunteers play a vital role in the success of our museum and we rely on dynamic and dedicated volunteers, just like you, every day. Please do be sure you have completed the application fully before submission and, if you have a resume available, please include that with your application form. General Information: We can t wait to meet you! Name Last First Middle Address Street City State Zip Phone (specify home/cell) Email Preferred contact method: Phone Email Your Organization/Group (if applicable) Emergency Contact: Name Phone Relationship Do you have any condition or disability for which you may require accommodation to perform the essential functions of a task or activity? Employer/School Title/Occupation If a student, are Highest level of education completed Please provide two personal references: Name Phone/ E-mail Street Address City, State Zip Are you seeking volunteer hours to fulfill court ordered community service? Y N
Personal Information and Experience: The Peoria PlayHouse Children s Museum offers many different volunteer opportunities and volunteer roles will continue to evolve over time. To better help us place you within available opportunities, please rank the following areas below by interest, if you have direct experience in each field, and/or any applicable skills. I m interested I m experienced (If so, please explain) Please list applicable skills Working with families Y N Working with children 0-3 Y N Working with children 4-8 Y N Working with children 9-12 Y N Science and engineering Y N Nature (horticulture, animals, ecosystems, etc.) Y N Language Arts and Literacy Y N Farming Y N Office support and mailings Y N Guest services Y N Do you possess any other skills or expertise that would be of benefit to the PlayHouse Museum? Do you speak any languages, other than English? Why do you want to volunteer for the Peoria PlayHouse Children s Museum?
What would make you a good PlayHouse Museum Volunteer? Availability: We ask that all volunteers give a minimum of 8 hours (two 4-hour shifts) per month. Once trained, we also ask that volunteers commit to at least one year of service. Check all that apply below: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Afternoon Evening Please complete the following: Have you ever been convicted of a misdemeanor (crime involving dishonesty or violence) or a felony crime? Yes No If yes, describe: (Conviction will not necessarily be a bar to volunteering. Every instance and explanation will be considered individually.) All regular volunteer assignments are contingent upon the successful completion of screening requirements, for example: background checks, driver abstract check and a drug screen. Driver s License or State ID Number Date of Birth Your signature authorizes the investigation of all information pertaining to the screening items as may be necessary. Signature of volunteer or parent/guardian Date
Peoria Park District Volunteer Liability Waiver Volunteer's Name (Please Print) Facility/Event/Project Assignment Title (If known) (If known) As a volunteer for the Peoria Park District or the parent/guardian of a volunteer, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume full responsibility of any injuries, including death, damages or loss which I or my minor child/ward may sustain as a result of participating in the volunteer program. I do hereby fully release and discharge the Peoria Park District and its officers, agents, servants, and employees from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may accrue to me on account of participation in the volunteer program. In the event of an emergency, I authorize Peoria Park District officials to secure from any licensed hospital, physician, and/or medical personnel or good samaritan first aid providers, any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that the Peoria Park District provides secondary medical expense coverage up to $5,000 for injuries incurred while performing my volunteer duties. I also understand that my personal health coverage or medic are/medic aid coverage must pay first. In addition, I hereby consent to the use of my photograph in Park District brochures, publications, slide presentations, etc. I have read and fully understand the above details of the volunteer program waiver and release of all claims and permission to secure medical treatment. Signature of Volunteer or Parent/Guardian A parent/guardian must sign for a minor. Date Thank you for applying. Please return the signed, dated Application (4 pages) to: Volunteer Coordinator PEORIA PARK DISTRICT 1125 W. Lake Avenue Peoria, IL 61614 FAX (309) 686-3352 PH (309) 681-2827 or 2822 volunteers@peoriaparks.org Revised 2/25/2015 For office use only: Date office received: Background check received: Volunteer accepted / denied Notified: Volunteer Position and Location: Project supervisor and phone:
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