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Human Resources

Volunteer Connection Services Form

Instructions: Please complete and submit your form below.
If you have trouble filling out this form, please visit Human Resources at 240 Water Street, Henderson, NV 89015 or call 702-267-1940

How did you hear about The Volunteer Connection?
Friend/Relative  Website  City Employee  Other  

Last Name

First Name

Middle_Name

Street Address and Unit # (if applicable)

City, State, Zip

Home Phone

Work Phone or Cell Phone

E-mail Address

Emergency Contact (name, relationship, phone number)

Have you ever been arrested or convicted of any crime?
Yes  No
(If yes, please explain, in detail, arrests, convictions, etc.)

Do you have previous Law Enforcement Experience?
Yes  No
(If yes, how many years, and in what capacity?)

Volunteer Experience and Availability

Experience 1
Date(s) Name of Organization
Responsibilities


Experience 2
Date(s) Name of Organization
Responsibilities

Are you a current City of Henderson Employee?
Yes  No
If so, please type title, department:

I am available to begin on this date:

Once a week  Twice a week  Daily  Other  

and can provide services as follows (days/hours):

Days Hours Hours Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Areas of Interest
Click all that apply.

Youth Program (Parks and Recreation)
Senior Services (Parks and Recreation)
Bird Preserve (Parks and Recreation)
Any Area (Parks and Recreation)
One Time Event (Parks and Recreation)
Office Setting (Parks and Recreation)
Courts (Municipal Courts)
Fire General (Public Safety)
Fire Training (Public Safety)
Police – Animal Shelter (Public Safety)
Police –Training (Public Safety)
Police – Other (Public Safety)
Other Setting (Public Safety)
Ongoing Event (Cultural Arts & Tourism)
Ongoing Assignment (Cultural Arts & Tourism)
Office/Admin Setting (Any City Department)
Any City Department (Any Area)
Specific Department (Any City Department)
      Department

Education and Skills

Name of Current Employer or School (include city and state)
Highest Grade Completed Degree(s) Held Special Training/License(s)
Computer and Other Skills Languages

Computer Skills
MS Excel   MS Word  Other  

Agreement, Consents and Releases, and Conditions

1. As a volunteer for the City of Henderson I agree to:
  • Observe the policies and procedures of the City and the Department to which I may be assigned
  • Participate in initial training as well as any additional training related to my services
  • Notify immediate supervisor when sick and/or otherwise unable to serve as a volunteer
  • Perform duties as outlined by the volunteer coordinator
  • Dress in business attire suitable to the assigned tasks
  • Immediately notify my supervisor upon my being charged with any crime
I hereby certify that all statements made in this volunteer service form are true. I acknowledge that any false statement, omission or misrepresentation on this form will be cause for refusal of placement or immediate cessation of my volunteer service at any time during the period of my placement. I understand that I am servicing at all times on a voluntary basis without promise, expectation, or receipt of compensation for my services. I understand that that this agreement can be cancelled at any time by either myself or the City of Henderson.

Please Initial to indicate you understand this statement  

2. Informed Consent and Release:

I, , offer to volunteer my services to the City of Henderson. I realize that I will not be compensated in any way (including cash, privileges, benefits or future employment). I understand that the Department and/or I can cancel this agreement at any time. I release the City of Henderson, its employees, agents, leaders, instructors, contractors, and volunteers from any liability for loss or injury to my person or property which might occur due to negligence or other acts or omissions. This release applies to any losses or injuries which may occur as a result of, or during my participation in, volunteer service. I realize that this release is a binding contract. I have read and understand this release. I knowingly and voluntarily sign below. The City may use my photograph for any official Department publications and/or productions.

Please Initial to indicate you understand this consent  

3. Conditions:

I fully understand, acknowledge and agree to the following conditions: The City of Henderson reserves the right to make the final decision on placement of volunteers. Background checks, review of current dated and provided motor vehicle records (if applicable) in accordance with City policy, will be conducted on applicants. Additionally, drug and alcohol screening tests may be conducted depending on the assigned responsibilities I am given as a volunteer. All statements made in this form are true and authorization is given to investigate all matters contained in this form. I authorize the City of Henderson to receive any criminal history information that may be contained in the files of any national, state, or local criminal justice agency. Any false statements or misrepresentations on this form will be cause for refusal of placement or immediate cessation of my services at any time during the period of my placement. I understand that the volunteer program does not qualify me for paid employment with the City of Henderson, and as a volunteer, I will not be entitled to any employee benefits, with the possible exception of workers compensation benefits, if applicable, and only to the extent provided by law.

Please Initial to indicate you understand these conditions  

 

Volunteer Authorization Signature / Date:


Signature/Date of Parent/Guardian, if volunteer is a minor:

 

Once a volunteer vacancy is available in the area of interest you
have requested you will be contacted for a background to be completed.
Thank you for your interest in volunteer services with the City of Henderson.

  

IF YOU ARE UNABLE TO SUBMIT THIS FORM, PLEASE VISIT THE CITY OF HENDERSON HUMAN RESOURCES AT 240 WATER STREET TO OBTAIN AN APPLICATION.