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Volunteer/intern service application


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VOLUNTEER/INTERN SERVICE APPLICATION



Name

Social Security Number: (use of SSN is voluntary)

Address

City/State/Zip

Home Phone

Cell Phone

CA Drivers License Number

Expiration Date

List Any Work Restrictions or Limitations you have:

Name of High School Attended:

Graduated  GED 

College Attended:

Degree Received or #Units/Hrs Attended:

College Attended:

Degree Received or #Units/Hrs Attended:

Please list your work experience below (if no prior work experience please state NONE). You may also submit a resume.

From:

To:

Name of Employer:

Job Title:

Salary:

Hours Per Week:

Job Duties:




From:

To:

Name of Employer:

Job Title:

Salary:

Hours Per Week:

Job Duties:




From:

To:

Name of Employer:

Job Title:

Salary:

Hours Per Week:

Job Duties:




From:

To:

Name of Employer:

Job Title:

Salary:

Hours Per Week:

Job Duties:




Criminal History: Have you ever been convicted or declared guilty of a misdemeanor or felony by any court?* (A conviction shall include a pleas, verdict or finding of guilt regardless of whether sentence is imposed by the court.)

If yes, please list dates and convictions below.



FAILURE TO DISCLOSE THIS INFORMATION WILL BE CAUSE FOR DISQUALIFICATION.

NO 

YES 





*Please read carefully the following that you may omit:

  1. Traffic violations for which the fine imposed was $100 or less (Any traffic violation over $100 must be shown).

  2. Any offense committed prior to your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law.

  3. Any incident that has been sealed under Welfare and Institutions Code Section 781 or Penal Code Section 120345.

  4. Convictions for violations related to marijuana of subdivision (b) or (c) of Section 11357 of the Health and Safety Code or a statutory predecessor thereof, or subdivision (c) of Section 11360 of the Health and Safety Code, or Section 11364, 11365, or 11550 of the Health and Safety Code prior to January 1, 1976, or a statutory predecessor thereof, two years from the date of such a conviction.




























Are you related by blood or marriage to any person presently employed by the City of Fresno?  YES  NO

If YES, please provide: Full Name, Relationship and the Department in which the individual(s) are employed.












Have you been previously employed by the City of Fresno?  YES  NO

If YES, please list Dates of Employment and position(s) held:











Volunteers/Interns assigned work having disciplinary authority or supervision over minors in the Parks, After School, Recreation and Community Services Department are required to complete a supplementary Criminal History questionnaire as required by statute (California Public Resources Code Section 5164).


I understand that I must complete the attached Release, Waiver and Indemnity Agreement as a condition of performing Volunteer/Intern service for the City of Fresno.
I understand and agree that any misstatements or omissions of material fact herein may cause termination of my voluntary service to the City of Fresno. I understand that the City of Fresno may conduct a criminal and/or DMV background check as permitted or required by law. I declare under penalty of perjury under the laws of the State of California that the statements made above are true and complete to the best of my knowledge and belief.


Signature:




Date:





Department Use Only:


Project Sponsor (Department/Division, City Council):

Project Start Date:

End Date:

Project Description and Location:




Comments:




Approved by (print name):

Signature:

Date:

1WAIVER AND INDEMNITY AGREEMENT



FOR VOLUNTEER/INTERN SERVICE

______ _____ (“Volunteer/Intern”) is providing voluntary services to the City of Fresno pursuant to his/her Volunteer/Intern Service Application, dated . In consideration of permitting Volunteer/Intern to serve, the Volunteer/Intern agrees to indemnify, hold harmless and defend City of Fresno and its officers, officials, employees, agents and other Volunteer/Interns from and against any and all loss, liability, costs and damages (whether in contract, tort or strict liability, including but not limited to personal injury, death at any time and property damage) incurred by City of Fresno or any other person, and from any and all claims, demands and actions in law or equity (including attorney's fees and litigation expenses), arising or alleged to have arisen directly or indirectly out of the intentional act or willful misconduct of Volunteer/Intern related to his/her voluntary service to the City of Fresno.
The Volunteer/Intern agrees that the City of Fresno and its officers, officials, employees, agents and other Volunteer/Interns will not be liable for any loss or damage to Volunteer/Intern’s owned, rented, leased, or loaned property or property in his/her care, custody and control. Further, Volunteer/Intern waives his/her right of recovery against the City of Fresno, its officers, officials, employees, agents and other Volunteer/Interns for loss or damage to his/her owned, rented, leased, or loaned property or property in his/her care, custody and control.
The Volunteer/Intern, for him/herself, his/her heirs, executors, administrators or assigns agrees and understands that he/she has been designated a “Volunteer/Intern” in accordance with City of Fresno Resolution No. 2005-157 and is deemed to be an employee of the City of Fresno solely for the purpose of Workers’ Compensation coverage, and agrees and understands that his/her sole and exclusive remedy for personal injury or death while performing services as a Volunteer/Intern shall be a claim for Workers’ Compensation benefits in accordance with the laws of the State of California. Further the Volunteer/Intern, for him/herself, his/her heirs, executors, administrators or assigns waives and relinquishes any interest or right to claim any interest in any other City of Fresno employment benefits offered employees of the City by reason of any common law employee rights theory or similar employment entitlements of any kind.
The Volunteer/Intern agrees that the contents of this document shall be binding upon his/her heirs, executors, administrators and assigns.
The Volunteer/Intern acknowledges that he/she (i) has read and fully understands the content of this Waiver and Indemnity Agreement; (ii) has been fully and completely advised of the potential dangers incidental to providing the voluntary service to the City of Fresno; (iii) has had the opportunity to consult with his/her attorney, in his/her discretion; and (iv) is fully aware of the legal consequences of signing this document.












Signature of Volunteer/Intern




Date










Signature of Volunteer/Intern’s Parent or Guardian (if minor)




Date










Witness




Date




Rev. 11/19/12


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