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City of Marysville Volunteer Application The City of Marysville operates a volunteer program that provides services organization-wide. The purpose of the program is to enable the City to take advantage of the extraordinary reserve of knowledge, talent, and skill possessed by volunteers within our community and to capitalize on these abilities to augment City services. The intent is also to provide a program which involves interested residents in local government while providing them the opportunity to perform work of value to the community. Last Name: First Name: M.I. Street Address: City: State: Zip: Home Phone: Work: Email: Are you over the age of 18? Yes No If not, give date of birth: Do you have, or can you obtain, a valid Washington State Driver’s License? Yes No WA state Driver’s License or ID Card Exp. Date: AVAILABILITY Long-term Short-term Special Project Circle the Days You Can Be Available for Volunteer Work: Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday Are you currently certified in CPR? Yes No First Aid? Yes No WHAT AREA(S) DO YOU WISH TO VOLUNTEER? Office Cultural Arts Programs Senior Programs Outdoor/Environmental Programs Day Camps Pre-School Programs Special Events Structural Maintenance Athletics Special Needs Programs Festivals Court Appointed Community Service Coach Service Hours for School Park Improvements Other: Horticulture Eagle Scout Project VOLUNTEER/WORK HISTORY Volunteer/Work/Organization Name: Address: Phone: To: From: Supervisor: Reason for leaving: Primary Duties: Volunteer/Work/Organization Name: Address: To: From: Supervisor: Reason for leaving: Primary Duties: ---PAGE BREAK--- CRIMINAL CONVICTIONS Have you been convicted of a felony or released from prison within the last ten (10) years, or have been convicted of a misdemeanor other than minor traffic offenses within the past three years? YES NO If Yes, Please Explain: Do You Have Any Medical Conditions Physical or Emotional That Should Be Taken Into Consideration in Arranging Volunteer Assignments? YES NO If Yes, Please Explain: EMERGENCY INFORMATION In Case of Emergency Please Contact: Phone: Notice to Volunteers Volunteers are not considered to be City of Marysville employees. Volunteer services are performed without compensation. Injury Compensation is provided through the Department of Labor & Industries. Volunteer service is considered to be creditable work experience. The data furnished on this form is furnished voluntarily and will be used to contact, interview and place volunteers. SIGNATURE IS REQUIRED To the best of my knowledge, the information herein is true and complete. I understand that falsification of this application is grounds for dismissal as a volunteer. Further I give permission for an authorized representative of the City to inquire of individuals about my ability to perform all aspects of the volunteer position for which I am being considered and I release the City of Marysville and those individuals/institutions that provide information from any liability that may arise from the provision of this information. As a volunteer for the City of Marysville, I am fully aware that the work associated with being a City Volunteer involves certain risks of physical injury or death. Being fully informed as to these risks and in consideration of my being allowed to participate in the City’s Volunteer Program, I hereby assume all risk of injury, damage and harm to myself arising from such activities or use of City or Marysville/Lakewood School District facilities. I also hereby individually and on behalf of my heirs, executors and assignees, release and hold harmless the City of Marysville, its officials, employees and agents and waive any right of recovery that I might have to bring a claim or a lawsuit against them for any personal injury, death or other consequences occurring to me arising out of my volunteer activities. I give permission to have my photo taken and used for publicity purposes by the City. I authorize any necessary emergency medical treatment that might be required for me in the event of physical injury and/or accident to me while participating in this program. Signature: Date: If Under 18 Parent or Guardian’s Signature: Date: ---PAGE BREAK--- CHILD AND ADULT ABUSE INFORMATION DISCLOSURE STATEMENT State law (RCW 43.43) provides that the City of Marysville must require applicants for City jobs and volunteer positions to provide certain information to the City prior to employment or involvement with the City. This information will be kept confidential. Please disclose the following: 1. Have you ever been convicted of a crime against persons? YES NO (For purposes of this section, crimes against person means the conviction of any of the following offenses: aggravated murder, first or second or third degree assault or kidnapping, first, second or third degree rape, first, second or third degree statutory rape, first, second or third degree robbery, first degree arson, first degree burglary, first or second degree manslaughter, first or second degree extortion, indecent liberties, incest, vehicular homicide, first degree promotion prostitution, communication with a minor, unlawful imprisonment, simple assault, sexual exploitation of minors, first or second degree mistreatment, or any of these crimes as they may be renamed in the future. See RCW 43.43.830 for a complete list of crimes.) 2. Have you been found in a dependency action under RCW 13.34.030 to have sexually assaulted or exploited any minor or to have physically abused any minor? YES NO 3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused, exploited, or to have physically abused any minor? YES NO 4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any minor or to have physically abused any minor? YES NO (For purposes of this section, a disciplinary board final decision means any final decision issued by the disciplinary board or the Director of the Department of Licensing for the following businesses: Chiropractic, dentistry, dental hygiene, drugless healing, massage, midwifery, osteopathic, physical therapy, physician, practical nursing, and real estate brokers and salesman). If your answer is yes to any of the above questions, provide the date and location of all such findings. FINDINGS DATE COUNTY & STATE NOTICE: The information you have provided will be processed through the Washington State Patrol Criminal Identification Unit for a Records Examination to determine if you have any convictions of offenses against persons adjudications or child abuse in civil actions or disciplinary board final decisions. A copy of the State Patrol’s response will be made available within ten (10) working days of receipt by the City of Marysville. UNDER PENALTY OF PERJURY, I certify that the above information is true, correct and complete. I grant permission to the City of Marysville to make an inquiry to the Washington State Patrol under the provisions of this law. I understand that if I am given a volunteer assignment, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am assigned, my position is conditioned on your receipt of a satisfactory report from the Washington State Patrol. Signature Name (Print) Address Here: ---PAGE BREAK---