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Position Applying for: Volunteer □ □ □ □ □ □ □ If yes , for what Service Project at which School/Youth Group? PLEASE PRINT CLEARLY □ □ □ □ revised 10/2018 Offense: Have you ever been or are you currently a Registered Sex Offender?* Yes No *Answering “Yes” to the above questions does not constitute automatic rejection from volunteering. Page 1 of 3 Street Address City State Zip Code Have you ever been convicted of a felony?* Yes No If yes , County of conviction State Date Last Name First Middle Phone Street Address City State Zip Code Last Name First Middle Phone Employment Reference: Please include most recent or current employer. Organization/Company Name Start Date End Date Street Address City State Zip Code Position Supervisor's Name Phone Personal References: Please include those who have known you at least three years and who are not related to you. Email Address: Address: Number Street City State Zip Code Primary Phone: ( ) Alternate: ( ) Middle Is this a service for a Service Project for a School or Youth Group? Yes No Other Last First Name: Volunteer Application Douglas County Board of Commissioners An Equal Opportunity Employer M/F/V/H Douglas County appreciates your interest in volunteering. From helping County Administrative staff to outdoor activities to general assistance with the public needs, your community involvement is greatly appreciated. Race, religion, gender, national origin, age, veteran and marital status are not considered in the selection of Douglas County volunteers. For the benefit of our children, employees and citizens, all applicants must complete a volunteer application and consent form for a background check. Referral Source: Advertisement Self-Interest Email Friend/Relative Department Applying to: Animal Services Date: ---PAGE BREAK--- □ □ □ □ □ □ □ □ □ □ □ l l l l l l □ □ Availability: Morning 8-11 Lunch 11-2 Afternoon 2-5 Evening 5-8 Interests and Skills: Programs/Positions/Duties you would like to volunteer for: Thursday Friday I would like to work approximately hours per week. Saturday Sunday Monday Tuesday Wednesday Street Address City State Zip Code **Hours may not be exact shifts within your location; your Department will discuss actual hours available. Emergency Contact: Last Name First Middle Phone I certify and attest that all answers here are true and complete to the best of my knowledge. I authorize the Douglas County Board of Commissioners to investigate all statements and answers within this application and grant permission for them to retrieve my criminal and/or driving history record as a condition of my volunteer status and continued involvement as a volunteer. Signature of Applicant Date Signed FOR DEPARTMENT USE ONLY Applicant's Statement As a volunteer, I understand that I am not an employee of Douglas County and will not receive any direct or indirect compensation. I understand and agree to follow Douglas County’s behavioral policies for Merit System Employees, which include but are not limited to, sexual harassment, proper attire and customer service. I agree to hold Douglas County harmless from any claims resulting from my participation as a volunteer for County programs and activities. This includes claims for bodily injury, personal injury, loss, theft, personal property damage, loss of income or any consequential damages. I understand that Douglas County reserves the right to remove me from Volunteer status without notice or without reasons. Page 2 of 3 Interviewer's Remarks: Approved? Yes No Department Interviewed by (print) Interviewer's Signature Date Volunteer Position Department Head's Signature ---PAGE BREAK--- □ □ □ □ □ □ □ Please check if any are applicable: □ Disabled Veteran □ Vietnam Era Veteran □ Handicapped Individual Driving Not Driving Start Date: Human Resources Signature Date Hispanic Asian/Pacific Islander American Indian/Alaskan Native FOR HUMAN RESOURCES DEPARTMENT USE ONLY Department: Animal Services Position: Volunteer Applicant's Signature Date Please Check One: Male Female Please Check One: White/Caucasian Black/African American Street Address City, State and Zip Code / Social Security Number Date of Birth Driver's License Number/State DOUGLAS COUNTY BOARD OF COMMISSIONERS CONFIDENTIAL CONSENT FORM I hereby authorize the Douglas County Board of Commissioners to retrieve my criminal/driver's record as a condition of Employment/continued Employment and/or Volunteering/continued Volunteering and/or Internship/continued Internship with Douglas County Government. PLEASE PRINT CLEARLY Print Full Name (No Initials)