City of Santa Fe Springs Volunteer Application and Photography Waiver

Type of Volunteer*

Year round volunteerStudent volunteerOne Time Volunteer

Last Name*

First Name

Middle Name

Address*

Address

Street Address Line 2

CityState

Zip Code

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Cell Phone Provider

For Text Message Purposes Only

Date of Birth

MonthDayYear

Email*

example@example.com

Drivers License

Shirt Size*

Do you have any previous experience volunteering with the City of Santa Fe Springs?*

YesNo

If yes, please explain

Are you applying for school credit?*

YesNo

Are you Bilingual*

YesNo

If yes, what other languages do you speak?

Last grade completed (optional)

Name of your high school/college

What volunteer opportunities are of interest to you? *

EXAMPLE: If volunteering for the Float, type in FLOAT

Do you have any limitations to health or physical ability?*

YesNo

If yes, please explain:

Name*

Last, Middle, First

Relation to Volunteer

Home Phone:

Area CodePhone Number

Cell Phone: *

Area CodePhone Number

Name of Parent(s) or Guardian(s)

Please include last, middle, first name

Home Phone:

Area CodePhone Number

Cell Phone:

Area CodePhone Number

Parent/Guardian Signature

Date of Signature

I certify that all statements on this application are true and complete. I understand that any false information or incomplete statements will subject me to disqualification or dismissal from any volunteer position with the City of Santa Fe Springs. I further understand that placement in a volunteer position is contingent upon TB test and background clearances (if applicable).

Volunteer Signature:*

Date of Signature

I hereby acknowledge that as a volunteer for the City of Santa Fe Springs (“City”) in the capacity of a Community Service Volunteer, I am not an employee of the City. I intend to perform voluntary services for the City without compensation. I am not an employee of the Agency, but that I am covered under the Agency's workers' compensation plan since the Agency has adopted a resolution extending workers' compensation coverage to certain volunteers in specified categories pursuant to Labor Code Section 3363.5. As a volunteer who is covered under the Agency's workers' compensation plan, I expressly agree and acknowledge that workers' compensation is my exclusive remedy for any injury suffered while performing said volunteer duties, and that I cannot and will not seek to bring any other claim or actions of any type whatsoever against the Agency, its employees, officers, agencies, other volunteers and officials. No promise, inducement, or agreement has been made to me to induce me to release the City from liability for any personal injury and/or property damage incurred by me as a result of my voluntary services, nor has any promise, inducement, or agreement been made to me in return for the express waiver of rights referred to above. PHOTOGRAPHY RELEASE: I hereby grant the City of Santa Fe Springs and its representatives’ permission to use and/or publish photographic pictures in which I or, the individual(s) named herein, may be included for promotion or other City purposes. I hereby release, discharge, and agree to hold harmless the City of Santa Fe Springs and its representatives from any liability, including but not limited to, claims for libel or invasion of privacy.

If you wish to grant permission to use your photographs, please write down your initials in the box below.*

Signature*

Date of Signature

Name*

First NameLast Name

Parent or Guardian Signature (If Minor)

Personal Information

Volunteer Opportunity Interest

Limitations or Restrictions

Emergency Contact

For Minors Only

CERTIFICATE OF APPLICANT

Volunteer Program Waiver and Release