Volunteer Information
1. Personal Information (The "*" indicates a required value)
Are you at least 18-yrs. old?
Name: *
Home Address: *
City/Town: *
ZIP Code: *
(Street Number/Name, Rural Route, P.O. Box #)
Contact Telephone #: *
Alternate Telephone #: *
E-Mail Address: *
The following information will only be used if a background check is required for the volunteer job you will be performing.
Birthdate: (mm/dd/yyyy) 
DL or State ID #: 
2. Volunteer Survey
 
   hours of volunteer service for:    


  
   

Please describe why you are required to complete these hours:

Please list any special accommodations that you may need to participate in volunteer opportunities: 

Please list days and times you are available:

 
Do you have your own transportation?
Explain:
3. Interests and Skills
I am interested in volunteering in the following areas (check as many as apply):



      
      
      
      
      
      
      





      
      



      
      
      
      
      
      
      
       
      





 
4. Other Information

Please list any skills or talents that may be useful as a volunteer:
 

Please describe any prior employment or volunteer experiences that may be useful as a volunteer:
 
 
5. Disclosure Statement
Have you ever been convicted of a crime? 
   
6. Release of Liability and Confidentiality Agreement
This agreement and release of liability is between the Volunteer and Newaygo County Community Services, its employees, members, agents, and affiliates, hereby referred to as NCCS.

To the best of my knowledge, the information on this sheet is true and accurate. I hereby authorize NCCS to conduct a background investigation if necessary for my volunteer duties. I authorize NCCS to disclose pertinent information to other agencies, organizations, churches or individuals for the purpose of sharing volunteer information. I release NCCS from any liability for use of images which include myself or family members generated for public relations including but not limited to: printed publications, videos, TV, internet, and website.

I agree to waive and release NCCS of any and all liability that could be incurred as a result of my negligence, intentional or unintentional, during my responsibilities as a volunteer for NCCS. I further release NCCS of all liability with regard to any physical or emotional harm that I may sustain during the time I volunteer at NCCS or in any other activity sanctioned by NCCS. I agree to indemnify and hold harmless NCCS for any costs or liabilities which may occur as a result of my volunteering at NCCS. As a volunteer at NCCS, I will receive no financial reimbursement for services rendered.

Through my volunteer work with NCCS programs and services, I will have access to information that is considered private. I acknowledge that this information must not be shared with others. In accepting this volunteer role with the agency, I agree to keep all information about program participants, staff, volunteers, and donors confidential. I will not copy, transcribe, record, or memorize confidential information for any reason other than for the limited purpose of providing the assigned services at NCCS.

I have had the opportunity to READ and UNDERSTAND this agreement and acknowledge that by signing this document, I am waiving certain legal rights in the event of injury. This agreement shall be governed by and construed in accordance with the laws of the State of Michigan. BY SIGNING BELOW, I accept and agree to the terms contained above.
*Do you agree with the Release of Liability and Confidentiality Agreement? 

     
*By selecting 'Yes', you are effectively applying an "electronic signature" to your consent of the above Release of Liability and Confidentiality Agreement

Please note that if you are under 18 years old, a parental consent form is required before volunteering.
 
© 2010 NCCS | 6308 S. Warner Ave PO Box 149 | Fremont, MI 49412 | Phone: (231) 924-0641 | Fax: (231) 924-5594