Fillable Form 4125 Volunteer Application (City of Dallas)

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Form 4125 Volunteer Application (City of Dallas)

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The Form 4125 Volunteer Application (City of Dallas) form is 3 pages long and contains:

  • 2 signatures
  • 27 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

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City of Dallas Volunteer Application
June 2020
CITY OF DALLAS
VOLUNTEER APPLICATION FORM
APPLICANT INFORMATION
Full Name
Street Address
City, State ZIP
Phone Number
Email Address
Date of Birth
(some positions
require a minimum age; DOB also
used for background check)
Driver License Number
and State of Issuance
SPECIAL SKILLS OR QUALIFICATIONS
Skills – what skills do you have from employment, previous volunteer work, or through other activities
(such as hobbies or sports) that would be helpful in our organization?
Please describe your experience working with the public.
AVAILABILITY
When are you available to volunteer? Please check all times/days in the appropriate boxes)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning
Afternoon
Evening
VOLUNTEER POSITIONS
In what department are you interested in volunteering?
□ Police
□ Aquatic Center
□ Fire
□ Library
□ Parks
□ Special Events
Other:
City of Dallas Volunteer Application
June 2020
REFERENCES
Personal Reference
Name
Address
Telephone Number
Relationship
Volunteer or Paid Reference
Name
Address
Telephone Number
Relationship
EMERGENCY CONTACT INFORMATION (required)
Name
Phone Number
Relationship
CRIMINAL HISTORY
Have you ever been convicted of a crime? □ Yes □ No
If yes, please explain fully below: (exclude cases processed in juvenile court and minor traffic
violations). Conviction does not necessarily disqualify you from a volunteer position.
RELEASE AND ACKNOWLEDGEMENT
I hereby certify that this application contains no misrepresentations or falsifications and that
the information given is true and complete to the best of my knowledge and belief. I authorize
the City of Dallas to make any necessary and appropriate investigations to verify the
information I provide in my application and to investigate my personal, professional, and
financial credit background, including any criminal records and past employment records. I
also release the City of Dallas and any persons, companies, or corporations supplying the
above information from all liability pertaining to information concerning my background.
I acknowledge that the City of Dallas will not provide health or accident insurance for my
benefit and that I am responsible for providing my own health or accident insurance. I further
City of Dallas Volunteer Application
June 2020
acknowledge that I am not entitled to and will not receive any employment or workers’
compensation benefits from the City of Dallas. I understand and agree that I or my estate will
be responsible to pay any and all costs incurred as a result of injury, illness, or death suffered
while participating as a volunteer or intern. This acknowledgment and agreement will be
binding on me and my heirs, personal representatives and successors.
Completing this form is not a guarantee of placement. I understand that as a volunteer, I am
not an employee of the City of Dallas and that any duties I perform are as a volunteer. I agree
to follow the procedures and guidelines set forth by the City of Dallas for my assigned work
duties.
Signature
Date
If you are under 18 years of age, your parent or guardian must complete the following:
I give my permission for my child/ward to volunteer for the City of Dallas.
Signature of
Parent/Guardian
Date
Return this form to:
City of Dallas
Human Resources
187 SE Court Street
Dallas, OR 97338
or email to Emily.gagner@dallasor.gov
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Form 4125 Volunteer Application (City of Dallas)

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Completed 14 July 2020

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