Fillable Canton Community Adult Volunteer Application Form (Please print) (Canton Township)

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Canton Community Adult Volunteer Application Form (Please print) (Canton Township)

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The Canton Community Adult Volunteer Application Form (Please print) (Canton Township) form is 4 pages long and contains:

  • 3 signatures
  • 10 check-boxes
  • 83 other fields

Country of origin: US
File type: PDF

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Canton Community Adult Volunteer
Application Form (Please print)
Please return this form to:
Canton Leisure Services
1150 S. Canton Center Rd.
Canton, MI 48188-1699
Phone: 734/394-5191
Fax: 734/394-5319
Name: Birthday: /
First Last Month / Day
Phone: ( ) ( ) ( )
Home Work Cell
Address:
Number Street City Zip
E-Mail Address:
What is your reason for volunteering?
From Canton Leisure Services website list what volunteer opportunities you are
interested in:
Waiver for Volunteers
I hereby agree to indemnify and hold harmless the Township, its elected and appointed officials,
employees, and agents, from any and all risks, claims, demands, damages and other liabilities
arising from my participation as a volunteer, including all costs, expenses and attorney fees paid or
incurred, by reason of personal injury, including bodily injury or death and/or property damage,
including loss of the use thereof, which arises out of, or is in any way connected or associated with
my activity as a volunteer for the Charter Township of Canton.
By checking “yes”, I certify that the information contained in this form is accurate. I Agree: Yes No
I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the
signer, and further that I agree to the above Terms of acceptance: Yes No
___________________________________
Participant’s signature or Parent/Guardian’s
signature, if participant is under the age of 18
___________________
Date
For Administrative Use Only
Revised: 3/8/2019
□ Background Check Rcd: □ Driving Record Check Rcd:
Visit Canton Leisure Services website at www.cantonfun.org for volunteer opportunities.
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signature
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Canton Township Leisure Services Department
Volunteer Emergency Medical Information Sheet
Name_______________________________________________Date of Birth________________________
Address______________________________________________________________________
City____________________________________ Zip__________________________________
Phone Number___________________________Other Phone Number_____________________
In case
of emergency, notify______________________________________________________
Relation to Employee ___________________________________________________________
Phone Number__________________________Other Phone Number______________________
2nd Emergency Contact _________________________________________________________
Relation to Employee___________________________ Phone Number __________________
The information below is designed to provide you with proper medical care in the event of an emergency
and is VOLUNTARY- completion of the below is OPTIONAL:
Allergies/sensitivities:_________________________________________________________________
Medical conditions the Township should be aware of:________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Medications:___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
The information I have provided above is accurate. I understand and acknowledge that this information
could be made available to any employee who could assist me in the event of an emergency.
______________________
Date
______________________
_________________________________________
Volunteer's Signature
_________________________________________
Parent/Guardian of Volunteer (if minor)
Date
Revised 5/10/2017
In
ternal Use Only
___ Original sent to CLS Administration Office ___ Copy sent to volunteer's work site
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signature
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Charter Township of Canton
Leisure Services Department
Authorization for Criminal Background Investigation
Full Name: ______________________________ _____________________________ ___________________
Last F
irst Middle
Home Phone: _________ _____ Date of Birth: __________________
Present Address:__________________________________ City: ____
Zip: Gender: Race: __
Have you lived outside of Michigan in the past twelve months?
YES NO
If YES, please indicate previous address on the back of the form.
Have you ever been convicted by plea or trial of any crime including traffic offenses? YES NO
I
f YES, please indicate your conviction on the back of the form.
D
river’s License Number: _____ State: ____ Exp. Date: _____________
CERTIFICATION STATEMENTS
I certify that the above statements are true and that the making of false statements may be considered sufficient
cause for immediate dismissal upon discovery thereof. I understand, and agree, that any misleading information or
omission of information may be cause for dismissal.
I specifically authorize the Charter Township of Canton, its agents, and its employees to make inquiries of courts, law
enforcement agencies, and other entities for records of criminal convictions.
I understand that it is the intent of Canton Township to deny participation to any person who has been involved in or
convicted of a any criminal activity that may be harmful to the Township, the activity or the participants. I understand
that any inappropriate and/or unacceptable conversation or conduct with any participant may be grounds for
immediate dismissal.
I also understand that Canton Township reserves the right to submit random checks on individuals at any time.
I agree to hold the Charter Township of Canton, its agents, volunteers, officers, elected officials, employees and all
parties involved harmless from any actions arising out of any criminal records check that may be done.
By checking “yes”, I certify that the information contained in this form is accurate. I Agree:
Yes No
I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the signer,
and further that I agree to the above Terms of acceptance: Yes No
______________________________________________ _________________
Signature Date
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signature
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Additional Information for
Authorization for Criminal Background Investigation
Previous Address(es) - within past twelve months
Address _______________________________________ City ______________
Zip_______________
Dates Residing At That Address __________________________________________________
Address__________________________________ City___________________
Zip_______________
Dates Residing At That Address __________________________________________________
Convictions (by plea of guilty, no contest or trial):
Court Where Date of
Name of Offense
Conviction Occurred Conviction
Police Department or
Agency
_________________ _________ ___________________ ____________________
_________________ _________ ___________________ ____________________
_________________ _________ ___________________ ____________________
List all convictions whether they have been expunged, purged, dismissed or otherwise resolved after a
conviction.
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Canton Community Adult Volunteer Application Form (Please print) (Canton Township)

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Completed 31 January 2021

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