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Victim Services Park County Sheriff’s Office P.O. Box 604, Fairplay, CO 80440 Sheriff Tom McGraw “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” MARGARET MEAD Dear Perspective Volunteer: Thank you for your interest in becoming a volunteer employee for the Park County Sheriff’s Office Victim Services Program. Our program provides an essential service for victims of crime in our community and we could not do this without the help of our dedicated volunteer staff. Included with this letter is an application, please fill in all information and return it to the Fairplay Sheriff’s Office or the Bailey Substation. Upon successful completion of the background check, 40- hour training, and finger printing, all new Volunteers will be sworn in by the Sheriff as Volunteer Park County Sheriff’s Office Employees. We look forward to including you in our group of professional, well-trained and dedicated individuals. Sincerely, Mary Pat Bowen Director, Victim Services Park County Sheriff’s Office ---PAGE BREAK--- 1 Park County Sheriff’s Office Victim Services Volunteer Application Contact Information: Name: Date: Address: City: Date of Birth: Emergency Contact: Address: Phone: Education/ Experience: Languages you speak (other than English) fluently: Last grade attended: High School 12 11 10 9 College 1 2 3 4 Major: School or special Volunteer & unpaid work experience: Please indicate specific skills: Accounting General Legal Legislation Professional Counselor Medical Training__________ Public Relations Writing Skills Tell us about you: (list any activities, affiliations, hobbies & special interests) Have you ever been a victim of If yes, (and feel comfortable in doing so) please Have you had any previous experience in working with victims? ---PAGE BREAK--- 2 Do you have your own? (Please provide copies of DL & insurance) Transportation Valid DL (please list Insurance Employment History & References: Current, or most recent employer: Address: Duties or title: Dates of employment: Name of supervisor: Employment History & References: Employer # Address: Duties or title: Dates of employment: Name of supervisor: Personal References (list two; not relatives or former employers) 1) Name: Address: Phone how long: _________Occupation: 2) Name: Address: Phone how long: __________Occupation: How did you hear about ---PAGE BREAK--- 3 Why do you want to volunteer with the Park County Victim Services Program?________ What does volunteerism mean to What is the most important to you in a volunteer Are you willing to give a minimum of one-year commitment to the program? (With the exception of vacations or What skills or interests would you like to develop or learn more about? Criminal History: Have you ever been arrested for any reason? (If yes, ---PAGE BREAK--- 4 Have you ever been convicted of any crime? (If yes, Have you ever used any illegal If so, Do you have any driver’s license If so, what are Additional I understand that any misstatement or omission of information called for herein may be sufficient grounds for my discharge. I authorize investigation of all statements contained herein. Signature of Applicant Date ---PAGE BREAK--- 5 VOLUNTEER AGREEMENT I, agree and understand that I am responsible to be fully alert and functional when “on duty” as a volunteer victim advocate. If I am incapable of functioning/not fully alert, due to medication effects or any other factors, I am responsible to report this to my supervisor/s immediately. If I am observed by others to be impaired in any way, whether due to medication effects and/or other factors, I will be relieved of my responsibilities and I will review further assignments with Victim Services program supervisors. CONFIDENTIALITY STATEMENT I understand that, as an employee or volunteer for this department, may have access to many files and other information about individual cases; ongoing investigations and other matters that are not for public ‘consumption’. The official business of the Park County Sheriff’s office is confidential as far as employees and volunteers are concerned, and information obtained on the job should be left at the office and not discussed outside the office, even with family members. Violations of confidentiality are considered amount the most serious violations requiring severe sanctions and may include termination at the discretion of the Director of Victim Services, Undersheriff and/ or Sheriff. ---PAGE BREAK--- Rev: 04/2005 Form: PCSO-A 21 EMPLOYMENT AGREEMENT As a condition of employment, I agree to conform to all rules, regulations, and/or the Park County Sheriff’s Office Policy Manual promulgated by the Park County Sheriff’s Office, the Park County Sheriff and/or his or her designees, and acknowledge that these rules, regulations, and/or the Park County Sheriff’s Office Policy Manual may be changed, interpreted, withdrawn, or added to by the Park County Sheriff or his designee(s) at any time at the Park County Sheriff’s sole option and without any prior notice to me. I further acknowledge that my employment may be terminated and any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn with or without cause, and with or without prior notice, at any time, at the option of the Park County Sheriff or myself and that any agreement to the contrary is invalid unless it is in writing and signed by the Park County Sheriff. I understand that any offer of employment by the Park County Sheriff is contingent on me providing consent to the administration of, and the results of, any urinalysis, physical exam, exam, or other recognized procedure including polygraph examination and that I may be required to undergo additional alcohol and/or drug screening, exam or other recognized procedural testing, polygraph examination, or counseling during the course of my employment. I HAVE READ AND FULLY UNDERSTAND AND AGREE TO THE ABOVE EMPLOYEE AGREEMENT WITHOUT ANY RESERVATIONS WHATSOEVER. Signature of Applicant Date POLICY DISCLAIMER Park County Sheriff retains the right to add to, subtract from, or other Park modify any part of this policy as deemed necessary without providing advance notice or cause. Interpretations of the terms and provisions contained in this policy are reserved to the Park County Sheriff. Any agreement with regard to this or any other policy is invalid unless it is in writing and signed by the Park County Sheriff. STATE OF COLORADO § COUNTY OF PARK § Before me personally appeared who says he executed the above instrument of his own free will and accord with full knowledge and agreement to the purpose thereof. SWORN AND SUBSCRIBED BEFORE ME this the day of Notary Public Signature SEAL ---PAGE BREAK--- Rev: 04/2005 Form: PCSO-A 22 PERSONAL INQUIRY WAIVER AUTHORITY FOR RELEASE OF INFORMATION I respectfully request and authorize you to furnish to the Park County Sheriff’s Office any and all information that you may have concerning me, my work record, school record, reputation, financial and credit status and any other information requested, including, but not limited to, medical, physical, and mental records or reports, including all information of a confidential or privileged nature, and photocopy of same, if requested. This information is to be used to assist the aforementioned Office in determining my qualifications and fitness for the position I am seeking with the Park County Sheriff’s Office. I hereby release you, your organization, or others from any liability or damage which may result from furnishing the information requested above. Signature of Applicant Date Home Address City State Zip STATE OF COLORADO § COUNTY OF PARK § Before me personally appeared who says he executed the above instrument of his own free will and accord with full knowledge and agreement to the purpose thereof. SWORN AND SUBSCRIBED BEFORE ME this the day of Notary Public Signature SEAL ---PAGE BREAK--- Rev: 04/2005 Form: PCSO-A 23 CONFIDENTIAL INFORMATION AGREEMENT A thorough investigation will be conducted to determine your qualifications for the position applied for. To a great extent your employment will depend on information obtained in confidential interviews with persons with whom you have been associated. Information will be obtained through interviews, polygraph examinations, evaluations, credit reports, and documents of a confidential nature. Applicants will not have access to such information; furthermore, since the information is confidential, the Office does not reveal the reason(s) of rejection for those applicants who are not accepted. If the reason(s) for your non-acceptance is of a temporary nature whereby you could be accepted at a later date, you will be so notified. Signature of Applicant Date of Birth Date STATE OF COLORADO § COUNTY OF PARK § Before me personally appeared who says he executed the above instrument of his own free will and accord with full knowledge and agreement to the purpose thereof. SWORN AND SUBSCRIBED BEFORE ME this the day of Notary Public Signature SEAL ---PAGE BREAK--- Rev: 04/2005 Form: PCSO-A 24 EMPLOYMENT POLICY I understand that if I fail to successfully complete my minimum twelve (12) months probation period or if I terminate my employment with the Park County Sheriff’s Office at any time and for any reason before completing one full year of service, that I will be responsible for the cost of any equipment and/or uniforms issued to me as well as the expense of any and physical examinations. Signature of Applicant Date STATE OF COLORADO § COUNTY OF PARK § Before me personally appeared who says he executed the above instrument of his own free will and accord with full knowledge and agreement to the purpose thereof. SWORN AND SUBSCRIBED BEFORE ME this the day of Notary Public Signature SEAL ---PAGE BREAK--- Rev: 04/2005 Form: PCSO-A 25 FREEDOM OF INFORMATION ACT Under the Freedom of Information Act, names, addresses, and telephone numbers of employees of the County may be released upon written request of any person, unless the employee has specifically requested the information not be made public. I, DO DO NOT want personal employment information released under the Freedom of Information Act. Signature Date