Fillable 193 Submit An Application (City of Liberty Lake)

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193 Submit An Application (City of Liberty Lake)

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City of Liberty Lake
22710 E Country Vista Drive
Liberty Lake, WA 99019
(509) 755-6700
The City of Liberty Lake appreciates your interest in its VOLUNTEER PROGRAM.
Please complete all the questions below. All information will be kept confidential.
Youth
Adult
Senior
Elementary Middle School High School
City of Liberty Lake
Volunteer Agreement
I certify that all statements on this application are true and complete to the best of my knowledge. I hereby authorize
the City of Liberty Lake to investigate any information contained in this application. I understand that false or
misleading statements shall be sufficient grounds for disqualification from the City's Volunteer Program. Further, I
understand that as a Volunteer, I am offering my services of my own free will without any expectation of compensation,
benefits, or insurance of any kind.
I voluntarily agree to participate, or for my child to participate, in this program. I hereby waive, release, and hold
harmless from any liability or claims for damages for personal injury, including death, as well as from claims for property
damage which may arise in connection with the above named activity, against the supervisor, the City of Liberty Lake
and its elected and appointed officials, agents, and employees. By participating in the herein mentioned program, I or
my child understands the potential risk for injury. As parent/guardian, I hereby consent to treatment of my minor child for
any and all medical procedures deemed necessary, as a result of accident or injury. I further agree to pay any and all
costs incurred as a result of said treatment. I hereby give permission to the City of Liberty Lake to use my, or my
children's photographs, as they see fit in their recreation brochure or other advertising. I understand the photograph
belongs to the City of Liberty Lake and I will not receive payment of any kind.
I hereby agree to the Volunteer Agreement set forth on this ______ day of ___________________, 20_____.
Volunteer Signature: ____________________________________________________________
Parent/Guardian Signature (if minor): _______________________________________________
CITY OF LIBERTY LAKE
22710 E Country Vista Drive
Liberty Lake, WA 99019
Phone: 509-755-6700
Fax: 509-755-6713
Volunteer Background / Reference Check Authorization
I, the undersigned applicant for volunteer work with the City of Liberty Lake, Washington, and
in consideration of the review of my volunteer application, do hereby give the City, or an
independent third party investigating agency, authorization to conduct a complete investigation
of my professional and personal background, including but not limited to the information
contained in this application, credit, criminal, driving, interviews, and all information or
documentation related therein. I authorize all individuals, schools, and firms named therein to
provide any information requested about me.
I understand and agree to waive any and all claim(s) or cause(s) of action relating to or for the
use of any and all information gained through this investigation or release of information and
documentation, and promise to defend and hold harmless the City of Liberty Lake, Washington,
its officers and employees from any and all claim(s) or loss(es) arising from such investigation
and/or release of information or documentation.
It is my intention that any copy of this authorization shall be as effective as the original.
Printed Name _________________________________________________
(First) (Middle) (Last)
Current Street Address__________________________________________
State__________________________________ Zip________________
Date of Birth__________________________________________________
Social Security Number_________________________________________
Volunteer Signature____________________________________________
Parent/Guardian Authorization for
Background Check of Minor_____________________________________
Date________________________________________________________
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193 Submit An Application (City of Liberty Lake)

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Completed 3 August 2020

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