Volunteer Application Date:

Name : (Last)

(First)

Address: (Street)

(City)

Day Phone: ( ) Are you under age 18?

(Zip)

(State)

Eve Phone: ( ) _____YES

Nevada Drivers License # Class: Exp. Date: _____NO

Please answer the following questions. If the answer to any of the questions is YES, please give details to the right.

YES NO 1. Do you have a disability which may limit your ability to perform the job for which you have applied? 2. Have you, as an adult, been convicted of a violation of the law, excluding minor traffic violations? A YES answer will not automatically disqualify you. 3. Have you ever been discharged from a position? 4. Have you ever worked for the City of Mesquite?

____

____

_____________________________

____ ____ ____

____ ____ ____

_____________________________ _____________________________ _____________________________

EDUCATION: Check the highest grade you completed: 1 2 3 4 5 6 7 8 9 10 11 12 or more Certificate of Training, Licenses of Professional Registration

Are you presently employed (Check those that apply) Employed full-time Employed part-time Full-time student Part-time student

Temporarily unemployed Looking for work

Current Employer Name: Address:

Phone (

)

What type of volunteer job are you most interested in at present?

Day(s) you are available: Times

Sunday

Monday

Available Morning 7am/12noon Afternoon 12pm/5pm Evening 5pm/12midnight

Do you have reliable transportation? 10/07

Tuesday

Wednesday

Thursday

Friday

Saturday

What are your present goals for a volunteer job? (e.g., gain school credit, work experience, etc…)

Commitment: (Please circle) Length of assignment desired:

3 months

6 months

6-12 months

More than a year

Spot jobs

Special Projects

VOLUNTEER INTEREST AND SKILLS

I do these things: I have these skills & abilities to offer:

Very Well

Well

O.K.

Not at all

Comments

Speak & Persuade: Skill in expressing ideas; ability to influence others Teach & Train: Writing: Creative, grants, reports Record Keeping & Reporting: Filing, keeping neat accurate records; take minutes Using Statistics & Numbers: Ability to collect & analyze figures; compute & estimate Artistic Skills: Draw, paint, photograph, design

Please check the skill(s) you could bring to the City of Mesquite and the areas of interest you have. Skills

Interest

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___

___

Administrative Receptionist Data Entry Public Relations/Publicity Writer(Newsletter, Manuals) Sports/Coaching Design/Decoration Volunteer recruitment Letter writing Special Events Fire Computer systems Working with: (Check) Seniors Youth Assisting with children’s program Recreation/Classes/ Youth Activities Recruiting

Other skills and abilities (List and describe):

How did you hear about our volunteer program?

10/07

Skills

Interest

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___

___ ___ ___

Personal solicitation Telephone Courtesy Teacher/Trainer Research Public Speaking Set up & Clean up Painting/Drawing Cultural Arts Museum Survey-taking Marketing Word Processing Foreign Language, if so what languages? Public Speaking Police Function as Committee member

Have you been active as a volunteer with other organizations? If so, please list with whom, responsibilities and dates:

YES

NO

Would you be willing to be “on-call” for special assignments?

YES

NO

EMERGENCY INFORMATION Person to contact: Family Physician Are you presently under a physician’s care

Phone: Phone: if yes, please specify

Are you presently taking any medication?

if yes, please list them

Please list any allergies/existing medical conditions: Allergies: Existing medical conditions: If you are under 18, this must be completed by a parent or guardian: Parent/Guardian Name: Phone: Day Eve/Weekend I hereby certify that all statements made in this application are true and I authorize investigation of all matters contained in the application. I acknowledge that any false statements or misrepresentation on this application will be cause for refusal of placement or immediate dismissal at any time during the period of my placement. I am aware that a background investigation may be required before placement. I am aware that fingerprinting will be conducted for all volunteer positions. I agree to hold harmless the City of Mesquite, their officers, employees, and organizations co-sponsoring programs or activities, from and against and all liability arising out of or in any way connected with the volunteer program. I realize the City of Mesquite does not carry a specific insurance policy for volunteers.

Signature

Return Volunteer Application to:

10/07

Parent/Guardian Signature

City of Mesquite Personnel Department 10 East Mesquite Blvd Mesquite, NV 89027

Volunteer Application

Eve Phone: Nevada Drivers License #. ( ). ( ). Class: Exp. Date: Are you under age 18? _____YES. _____NO. Please answer the following questions.

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