The URL can be used to link to this page

Home My WebLink AboutVolunteer Applicationcm•oF A B--O- RN f`` e WASHINGTON Pg. 2.of3 City of Auburn Volunteer Application Why do you want to volunteer with the City of Auburn? tj �%,C41e� � 'fl, 41 ujio"14 Have you. previously volunteered at the City or any other entity?. \ / ` `I t Where V ou I( C yI 4( try t 6 Name �� ✓)'fi `�- trPi L i4i t What did you do?= Special Skills _ ACV Human Resources Department 25 WeO Main Auburn wA 98001 Phone: 253-931-3040 TTY: 253-288-3139 dU� V%ovia✓ ¢� I ®ye✓yam Yes 0 No (If YES, complete information below.) Do you have a high school degree or equivalentYes No - - When(Frogm/To) 0 / � % n Telephone Other applicable sclioo,/liug //pp�� -- Current or last job Ac cG L eL71 '�- jr' 1' �, y2 �1� j /� . Employed From V � � - To -o % f Employer. _SLG-- I2. YGO/t' ti Employer's Address 1 u l Street /J�- L City/ State Zip Briefly describe work duties - V t3G-ej-:5e'd eL\l a-i� Ie � � �/ fl il -G✓ ��y` fl �� SJ ,P�G t List references (non -relative) who can provide reliable information about you: NameLC,C... �� l I - Relationship to you ✓, Address L(-��.. �/ `t' L�' ��IIG'.s' `.�,K-(',. G()6 90�3 71 Street 1 r /'�t City State Zip Home telephone 4§ 3 e)yy `{�,�Email I�- l /T� - How long known �t�` - Name i t' l a-ti �''V 1 �' `�` V�. a• ao 4 Relationship 4o you T o ✓tide-O lrA�e= Address yj (9` ' Y L 11 j�, W l i ` 1 `11 e.- Street / City State - 1Zip, Home telephone tR06 ^ %(c� "QbVliaiI ` How long known r$ d Mah,L ao&, 9533 4(00"7 ADCrrYOF _ }}�J p i - Human Resomees Department . 7R�T Cl",J of L�llburn 25 West Main WASHINGTON {. 7 t * _ Auburn WA 98001 olun eer ApplIcaLlun .Phone: 253-931-3040 Pg..I of 3 _ iIt TTY: 253-288-3139 Volunteers are considered without regard to race religion, color, sex; sexual `or ienialron national or rgbn, creed, gage, marital 'status, veteran status, disability status, at, anyother basis prohibiter) by federal, state, or local law. Ifyou require accornnioelahon to - complete the application, or interview) process, please contact the Karnai Resources Depa7meni foie assistance 253-931-3040. Volunteer Position Applying For: Lrw' a, wt c - j arykq P , r �� C<✓e . ]' et,-k e See the Volunteer Opportunities sheet to indicate department(s) and/or position(s) you are interested in. Name \5h -et k Address r✓ ( ' T ✓ /� ��U �t dr/ l IN 1 > / G 00� Street - City State Zip Geld L� � Work Phone NL 4 Hoine Phone � 5 ;a_ a4 s 1*t2#Message phone Email L sAA(LeigcL ,S,s c96,ilefiL�// l(dT Emergency Contact Name Jo (i�- s7i`��'Lt-�e� Emergency Contact Work Phone � ��-�,� �"'=.3�i i� � Iiorire Phone Are you related to anyone working for the City of Auburn?(? YesXNO ld Vl 1 c 5 ', 5 , (y/ 'l` �,l Lc- cl c} -I C ✓ e7 Y If yes, Name tCM'5' 1-.7 �,btm tl �t fl'GIle7X j- Deparent"& - U"ttle l alien Fak- a. V�e t A, ; nYl le) Y c� If needed foe position, do you have a valid driver's license with no pending risk of los Yes ❑ No C' ,/ / 7 Driver's License Nunrbcr. �. ,y J A `7�"� T (J�- �'^ State issued from U%RJf%t n �Y , / - List any criminal convictions that yoahave pled guilty to,been convicted of, or been released from jail orpi"ison within the past 10 years for z criminal offense, including both misdemeanor and felony level convictions. This includes theft, assail narcotic, domestic violence, and any other types of convictions. Include traffic -related convictions if a driver's license is required for the volunteer position. Your criminal conviction background may be verified with the Washington State Patrol Indicate date and nature of all offenses: D Ir) DY 0 9,0 ry tom-, GE j4L Otto Do you have any special requirements or i edical conditions, physical or emotional that should be taken into consideration in arranging volunteer assignments? YesNNo If yes, please explain AVAILABILITY When can you stint? _ W VI LYI �i �1� t '"�! D. ✓1 i -� - -Q-�'` rL t How nrzny hours pet' week? ,r`+-� GG �g� For the days you want to volunteer, write in the hours you�NvooQuld be available (indicate a.m. or p.m.): Monday %C f Tuesday - 7 r1 / Wednesdayzo Thursday Friday p M Saturday Sunday AGMYOF Human Resources Depat Intent uRN City Of Auburn 25 West Main wASHINGTON 7 - Auburn WA 98001 Pg. 3of3 - Volunteer teem Application Phone: 253-931-3040 -TTY: 253-288-3139 - AGREEMENT FOR THE VOLUNTEER NON -COMPENSATED SERVICES PURPOSE: The purpose of this agreement is to outline the responsibilities of the City of Auburn in providing volunteer opportunities, and to create an understanding between the City of Auburn and the individual applicant. This agreement shall apply to persons voluntarily performing non -compensated services for the City, including recreational programs, senior center programs, academic internships, non -compensated practical work experience, municipal jail trustee duties, court ordered community service referrals and any other types of volunteer activities. AGREEMENT FORNON-COMPENSATED SERVICES: The applicaut agrees to abide by the information contained in the Volunteer Handbook and relevant City policies and procedures.'fhe applicant agrees to perform the volunteer services in a safe, responsible manner in accordance with descriptions of work. It is further understood that this agreement shall not in any way constitute nor create an employer/employee relationship between the City of Auburn and the applicant. The City of Auburn shall not be responsible for, nor liable for, nor shall the applicant be eligible to receive, any compensation or benefits as a result of this agreement, EXCEPT for Industrial Insurance medical aid benefits. VOLUNTARY WAI VER AND RELEASE: In consideration of the opportunity provided by the City of Auburn to engage in any one or more of the above -referenced activities the applicant as evidenced by signature below, agrees to indemnify and hold harmless, release and waive all claims he/she and/or his/her heirs, assigns or other successors and other associated parties for any and all loss, liability, cost, or damages arising out of or in any way connected with applicants volunteer activities. Applicant agrees not to appear for any volunteer services trader the influence of alcohol and/or illegal drugs. The applicant agrees to inform the supervisor at the beginning of the shift if taking over-the-counter or prescription medications which may impair the ability to perform the volunteer duties.. - This agreement may be terminated by either party upon written or r verbal notice by either party. Such termination shall be effective immediately unless otherwise stipulated by the parties. - - - I give permission to have my photo taken and. used for publicity purposes by the City. I authorize any necessary emergency treatment that might be required forme in the event of physical injury and/or accident to me while participating in the program. - I hereby certify that the facts I have provided in my application are fire and complete. Any misrepresentations can be tausg for immediate disqualification from the City's volunteer program. I hereby authorize a background investigation to -be conducted, and my employers and any references to provide information they may have concerning me. I hereby release them and the City of Auburn from all liability. Applicant eS � .G(/Yvb-' lc-err=ems" - Date Supervisor Date Department Head Date Human Resources Representative Date If this Agreement is for a community service referral, applicant must complete the following: Court Conviction of what offense Number of Community Service hours to be completed Applicant's counselor or probation officer Name ' Phone WATCH Search Results -No Match -Washington State Patrol Page 1 of 1 Monday, March 03, 2014 oo� off• �.' \. � � �• WASHINOTQN ACCE35 TO CRIMINAL H13TORY Web Search No Record Found Report Washington State Patrol Identification and Criminal History Section P.O. Box 42633 Olympia, Washington 98504-2633 Telephone (360) 534-2000 THE FOLLOWING WEB SEARCH NO MATCH FOUND REPORT IS FURNISHED FOR OFFICIAL USE ONLY This report was generated from a transaction run on 03/03/2014 at 15:34 Conviction Criminal History RCW 10.97.050(1) Pursuant to the purpose of inquiry, NO Record was found in the Washington State Criminal History Repository based on the descriptors provided: SPEIDEL,SHAENA ANNE DOB 11/24/1960 SEX F RAC U �� This may mean that the person you searched for has no criminal conviction record OR that your search criteria did not match the spelling of the person's name or date of birth. Positive identification or non -identification in the Washington State Patrol's database, can only be determined by fingerprint comparison. https;//forkess.wa.gov/wsp/watch/Inbox?rsPage=detail&LocalIndex=0 3/3/2014 ASHINGTON STATE PATROL OOP` PATROL Historyentification and Criminal • PO Box 42633 UO, Olympia WA 98504-2633 .0111 REQUEST FOR CONVICTION CRIMINAL HISTORY RECORD (RCW 10.97) INSTRUCTIONS: PLEASE COMPLETE THIS FORM WHEN REQUESTING CONVICTION CRIMINAL HISTORY RECORD INFORMATION FROM THE IDENTIFICATION AND CRIMINAL HISTORY SECTION. MAIL REQUEST TO ADDRESS NOTED ABOVE WITH $17,00 CHECK OR MONEY ORDER OR COME TO OUR OFFICE AT 3000 PACIFIC AVENUE, OLYMPIA, WA. NOTE: IT MAY TAKE 7 TO 14 BUSINESS DAYS FOR RESPONSE WHEN MAILED. FOR AN IMMEDIATE RESPONSE, ACCESS OUR WEB SITE LISTED ABOVE TO CONDUCT YOUR CRIMINAL HISTORY REQUEST FOR $10,00 USING A CREDIT CARD, NOTARIZED LETTERS ARE AN ADDITIONAL 55.00 PER NOTARY SEAL Notarized Letters) (available by mail only) NOTE: The requested record information is furnished solely on the basis of name and/or description similarity with the subject of your inquiry. Positive identification or non -identification can only be effected upon receipt of fingerprints. Applicant may be advised of inquiry. OSUBJECT INFORMATION: (Please type or prinitt clearly) �j Applicant's Name: �A �� `�-� 46ya K, r Last First Middle C / Alias/Maiden Name: // 7a Date of Birth: �" Z� IN Sex: Oft Race: �t Month/DayNear 0 REQUESTOR INFORMATION: (Please type or print clearly) DATE: / / Terry Mendoza, H.R. Asst. JQ �'/(eI��v!r� CL Me, Day Yr. (print) Name/fitle of Requester Requesto�sS nature r: Receive background results electronically Phone No. (253) 931-3040 Password (must be at least 8 characters) REQUESTOR'S ADDRESS:(ty pe or print clearly) City of Auburn Subject's Right Thumb Print (Optional) Name 25 W. Main Street Aduress Auburn WA 98001 City State zIP Code 3000-240-5G9 (R 9/10) ALUB CITY OF CITY OF AUBURN CRIMINAL CONVICTION H15TORY FORM List below any criminal convictions that you have had, including both misdemeanor and felony convictions. This includes any convictions related to drugs/narcotics, driving under the influence and other vehicular related, crimes against persons (assault, burglary, murder, etc.), trespassing, prostitution, theft; domestic violence, crimes of integrity, and any other types of convictions. Your criminal conviction background may be verified with the Washington State Patrol and an FBI criminal records check (through the finger printing process). I have no criminal conviction record of any kind. I have a cri/m�inal record with convictions) of and dates) occurred: %yYFil�`J'zI/1 ell r M. ✓; I. n.nn> G nLC I� 1 0txla, Q }! FI C, Applicants for employment or volunteering, and wHic�may have unsupervised access to children under sixteen years of age or to developmentally disabled persons, or vulnerable adults during the course of employment or involvement must disclose the following information: Have you ever been convicted of any crime against children or other persons (including but not limited to assault, robbery, burglary, rape, indecent liberties, molestation, arson, kidnapping, prostitution, vehicular homicide, murder)? YES_ NO-X-- Have you been found in any dependency action under RCW 13.34.040 to have sexually assau ted or exploited a minor or to have physically abused any minor? YES_ NO Have you been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or physically abused any minor? YES_ NO)( Have you been found in a disciplinary board final decision to have sexually or physically abused or financially xploited a minor or developmentally disabled person or vulnerable adult? YES_ NOA 1 understand that the City of Auburn may make inquiry to the Washington State Patrol or police agencies within other states in which I have lived under the provisions of applicable law. (You may obtain a copy of the background results by making a written request to the City of Auburn Personnel Department.) I certify under penalty of perjury that this form was completed as true and correct. Further, I understand that misrepresentation of any information on this form will result in cancellation of this application, or if employed, may be cause for dismissal. Applicant's Name (Print) Applicant's Signature Date of Birth Date Revised 3/13/08 CITY OF 1` • -• . - iAUL - By signing this form, I hereby give permission to my previous and current employers, peers and subordinates, and educational institutions to release information regarding my work performance and/or education/degree completion to representatives of the City of Auburn. I am aware that this release includes authorizing City representatives to review information contained in my personnel files at current and previous employers. I agree to hold harmless and indemnify all parties releasing this information. I also understand that a police background check and an FBI criminal records check (through a finger printing process) may be conducted as part of the selection process. I understand that disclosure of my Social Security ID number is voluntary. PI9,e,60 A."7) l Printed Name 4, Signature Date L:Aemployment\Forms\background Release Torm0306.doc Revised 03/2 V06 DRIVER'S LICENSE CERTIFICATION VERIFICATION and TRAFFIC VIOLATION FORM City policy 200-22 states that employees whose work requires that he/she drive a City vehicle must hold a valid Washington State Driver's License. My signature certifies that I presently hold a valid Washington State Driver's License. As this is a condition of volunteer service or employment, I understand that falsification of this claim may be grounds for dismissal. I will furnish to the City, upon demand, a current Department of Motor Vehicle Abstract of Driving Record, and will submit an updated Certification/Traffic Violation form upon request from the City. If my position requires a Commercial Driver's License (CDL), I authorize the City of Auburn to conduct a complete license and records check with the Department of Motor Vehicles/Licensing and periodically recheck validity and status. List below any and all motor vehicle related tickets, citations, charges, convictions, suspensions, accidents, revocations and other related activity you have experienced in the last 10 years: r �V&4 ✓I`v'C %-�Deerli`r V1G 3 i p, /Qd Ji �1G1 Signature Print Full Name Driver's License Number State l Date of Birth Expiration Date AGREEMENT FOR INDIVIDUAL VOLUNTEER SERVICES This Agreement is made, by and between the City of Auburn, a political subdivision of the State of Washington hereinafter referred to as the "City" and S kei & n y A, eJe. hereinafter referred to as the "Volunteer." (print name) PURPOSE: The purpose of this Agreement is to outline the responsibilities of the City in providing volunteer opportunities, and to create an understanding between the City and the Volunteer. This Agreement shall apply to persons voluntarily performing non -compensated services for the City, including but not limited to, practical work experience, recreational programs, senior programs, police resource centers, and academic internships. AGREEMENT FOR NON -COMPENSATED SERVICES: The Volunteer agrees to abide by all relevant City policies and procedures and to perform the volunteer services in a safe, responsible manner in accordance with the descriptions of service. It is further understood that this Agreement shall not in any way constitute nor create an employer/employee relationship between the City and the Volunteer. The City shall not be responsible for, nor liable for, nor shall the applicant be eligible to receive, any compensation or benefits as a result of this Agreement EXCEPT for State Labor and Industries Industrial Insurance medical aid coverage. In consideration of the City giving me permission to perform these volunteer services, I understand that: (Please initial the following) 1 am not to appear for volunteer service under the influence of any illegal drugs or alcohol. The Volunteer agrees to inform the supervisor at the beginning of the shift if taking any over-the-counter or prescription medications which may impair the ability to perform volunteer duties. 1 am not to have child(ren) with me, during my volunteer activities, that are under 14 years of age (excluding child participation in the program). If I do bring with me any child(ren) under 14 years of age (which is a violation of this agreement unless they are participating in the program), I understand I will be held solely liable, and assume all risk of liability, for my child(ren)'s actions and agree to hold the City harmless from any and all such related claims against the City; except for injuries and damages caused by the sole negligence of the City. I will abide by all City policies regarding personal conduct while performing volunteer services. I agree not to go beyond the scope of volunteer work agreed to without authorization CONTINUED ON BACK PAGE I am to be trained on any activity that I am unfamiliar with, learn the corresponding policies, and it is my responsibility to understand them completely or ask questions until I feel confident to perform them. Depending on the scope of volunteer work, the following policies may apply: Driving, Safety Procedures, Computer Operation, Dress Code, Anti Harassment, r, Confidentiality. Should an injury occur during the scope of my service the City has included my hours of volunteer service in the State Labor and Industries coverage for volunteer workers. I understand that I am to report any on-the-job injury o illness, no matter how minor, to G I j- ut4 ,',�in e50.a � C'� �%9� TERMINATION: I understand that 1 or the City may terminate this agreement at any time without cause, and that I am volunteering my services at will and may be asked to discontinue such without prior notice or reason. WAIVER &HOLD HARMLESS: 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 facilities. I also hereby individually and on behalf of my heirs, executors and assignees, release and hold harmless the City, 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. LIABILITY COVERAGE: I understand that the City is self insured through the Washington es Insurance Authority (WCIA) for liability coverage. Volunteers performing within the scope of their assigned duties as authorized by the City are afforded the same coverage as City employees under the City's liability coverage with WCIA. I am fully aware that a volunteer's intentional misconduct is not protected or covered by the City or WCIA. This agreement will be in effect for the duration of my volunteer services beginning this Dated this day of C�hQ��, 20 By: City of Auburn Volunteer's Signature Aar fr\ l�q P DO City/St�ate+/Postal Code., ^ l�^ d�J ;J � J'�Y5 � 9 I 2� Phone