Fillable Application City of Kelso Volunteers, Commissions, Boards and (City of Kelso)

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Application City of Kelso Volunteers, Commissions, Boards and (City of Kelso)

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Application
City of Kelso
Volunteers, Commissions,
Boards and Committees
Date Received
__________________
Personal Information
Last Name First Name Middle Initial
Address City State Zip
Home Phone Work Phone Email
Are you over the age of 18?
Yes No
Date of Birth
Do you have, or can you obtain a valid driver’s license?
Yes No
Driver’s License Number:
Availability & Skills
Availability
Long Term Short Term Special Project
Are you currently certified in CPR? Yes No
First Aid? Yes No
Check the dates you can be available for work (check all that apply)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
In what particular areas of volunteer work, commission, board or committee are you interested?
Board of Adjustment and Appeals
Stormwater Advisory Committee
Civil Service
Highlander Festival
Library Board
Lodging Tax Advisory Committee
Planning Commission
Housing Authority
Park Board
‘Big Idea’ Tourism Committee
Library
Train Depot
City Other:____________________________
What general skills/experience/education would you like to share in your work for the City of Kelso?
Criminal Convictions
Have you ever been convicted of a felony or released from prison within the last ten (10) years, or a
misdemeanor other than minor traffic offenses within the past three (3) years? (A conviction will not necessarily bar you
from appointment)
Yes No If yes, please explain:
Medical Considerations
Do you have any medical, physical or emotional conditions that should be taken into consideration in
arranging volunteer, commission, board or committee assignments?
Yes No If yes, please explain:
In case of emergency, please contact
Address/City/State/Zip
Phone
References (do not list relatives)
Name
Address/City/State/Zip
Phone
■
Notice to Volunteers
Persons appointed as volunteers, commission, board and committee members are not considered to be City
of Kelso employees. Injury compensation, however, is provided through the Department of Labor &
Industries. Services as a volunteer, commission, board or committee member are considered to be creditable
work experience.
The data furnished on this form is furnished voluntarily and will be used to contact, interview and place
volunteers and/or commission, board or committee members.
Signature is Required
To the best of my knowledge, the information herein is true and complete. I understand that falsification of
this application is grounds for dismissal as a volunteer and/or commission, board, or committee member.
Further, I give permission for an authorized representative of the City of Kelso to conduct a state patrol
criminal background check in accordance with RCW 43.43.830-839 and to inquire of individuals about my
ability to perform all aspects of the volunteer and/or commission, board or committee position for which I
am being considered. I release the City of Kelso and those individuals/institutions that provide information
from any liability that may arise from the provision of this information
As a volunteer, commission, board or committee member for the City of Kelso, I am fully aware that the
work associated with being a volunteer, commission, board or committee member involves certain risks of
physical injury or death. Being fully informed as to these risks and in consideration of my being allowed to
participate in these City programs, I hereby assume all risk of injury, damage and harm to myself arising
from such activities or use of City facilities. I also hereby individually and on behalf of my heirs, executors
and assignees, release and hold harmless the City of Kelso, its officials, employees and agents, and waive
any right of recovery that I might have to bring a claim or a lawsuit against them for any personal injury,
death or other consequences occurring to me arising out of my volunteer, commission, board or committee
member activities.
I give permission to have my photo taken and used for publicity purposes by the City. I authorize any
necessary emergency medical treatment that might be required for me in the event of a physical injury
and/or accident to me while participating in any of these programs/activities.
Signature
Date
If under 18, Parent or guardian’s signature
Date
Return completed and signed application to:
City of Kelso, City Manager’s Office
203 S. Pacific
PO Box 819
Kelso, WA 98626
Please call 360-577-3301 if you have any questions or need additional information.
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Application City of Kelso Volunteers, Commissions, Boards and (City of Kelso)

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Completed 23 January 2021

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