Fill - Free fillable City of Gardner Human Resources Department 95 Pleasant (CITY OF GARDNER) PDF form

City of Gardner

Human Resources Department

95 Pleasant Street, Rm. 14

Gardner, MA 01440

(978) 630-4001 ♦ Fax (978) 630-4025

Community/Volunteer Service Application

(Applicants must be 16 or older or between the

ages of 13 and 15 accompanied by a parent volunteer.)

Name:

Address:

Street City/Town State Zip Code

Home Phone: Email Address:

If applicable:

Total hours required: Date hours need to be completed:

When are you available to perform community service:

 Weekdays (please circle): Monday, Tuesday, Wednesday, Thursday, Friday

 Time of Day: (please circle): Mornings Afternoons

Preferred Location:  Library  Animal Shelter  Council on Aging

 Other: ________________________________________________

In case of an emergency or illness please notify:

Name: Relationship:

Address:

Street City/Town State Zip Code

Home Phone: Work Phone: Cell Phone:

Please check all of the ways in which you are available to assist as a volunteer:

 Clerical Support (filing, data entry, phone messages)

 Facility Cleaning (sweeping, mopping, dusting and general cleaning)

 Grounds Maintenance/Laborer (mowing, raking, trash removal, weeding, watering plants,

sweeping sidewalks and parking areas, snow removal, etc…)

 Other (please explain):

Community Service Application

Page 2 of 4

Rev. 04/2016

By submitting this application, I affirm that the facts set forth in it are true and complete. I

understand that if I am accepted as a volunteer, any false statements, omissions, or other

misrepresentations made by me on this application may result in immediate dismissal. I

acknowledge that I am required to follow all instructions given by my supervisor or his/her

designee, to perform all assigned duties and to follow all rules of the City of Gardner. I agree to

demonstrate a good attitude and willingness to perform the duties assigned in a pleasant manner.

While working for the City of Gardner, I will:

 Arrive clean, neat and appropriately attired.

 Not consume alcohol or illegal drugs before or during my volunteer work assignment.

 Not distribute literature of any type.

 Not bring other people with me during my volunteer working hours.

 Avoid the use of profanity while on site.

 Not engage in inappropriate behavior with employees, members of the public or other

volunteers.

Applicant Signature: Date:

If the applicant is under the age of 18 years old, a parent or guardian must sign his/her consent to

the terms and conditions of this application below:

Parent/Guardian Signature: Date:

Background Check

I understand that the City of Gardner will conduct a background check prior to acceptance as a

community service volunteer. I agree to provide the necessary information as requested and

further understand that said background check may include a review of sex offender registries

and/or criminal history records (CORI request form attached hereto for execution by applicant).

Applicant Signature: Date:

Indemnity

I, for myself, my personal representatives and dependents hereby release, indemnify and hold

harmless the City of Gardner (the “City”), its elected officials, directors, employees, agents and

other volunteers from any and all liability in connection with any injury I may sustain, including

any injury caused by negligence, in conjunction with the volunteer activities for the City.

Further, I, for myself, my personal representatives and dependents hereby release, indemnify and

hold harmless the City, its elected officials, directors, employees, agents and other volunteers

from all damages, judgments, expenses, including reasonable attorney fees, costs of liabilities in

law or equity suffered because of damage to my personal belongings or any property that may

arise out of, or as a consequence of my negligent or intentional acts while volunteering for the

City.

Community Service Application

Page 3 of 4

Rev. 04/2016

I understand that as a volunteer, I am not an employee of the City, that my involvement will not

lead to employment status, that I will not be eligible for employee benefits or worker’s

compensation insurance coverage and that I will receive no compensation for my services. I

understand that I must operate within the scope of the duties associated with my volunteer

position, a description of which will be provided to me should I be accepted and approved as a

community service volunteer for the City.

Applicant Signature: Date:

If the applicant is under the age of 18 years old, a parent or guardian must sign his/her consent to

the terms and conditions of this application below:

Parent/Guardian Signature: Date:

Community Service Application

Page 4 of 4

Rev. 04/2016

City of Gardner

Community Service Policy Agreement

I. Application

Community Service volunteers must complete an application, criminal background history consent and

execute indemnity agreements contained in the application form before work begins.

II. Specifications

Community Service volunteers must be 16 years of age or older or between the ages of 13 and 15

accompanied by a parent volunteer. The City of Gardner only accepts court ordered volunteers who have

committed Class C Misdemeanors that DO NOT involve the following:

• Crimes of moral turpitude.

• Current or past crimes of violence.

• Unstabilized mental issues.

III. Credit for Service

There is no payment or benefits for service. Time is given hour for hour.

IV. Conduct

Certain conduct will be expected of volunteers while working for the City of Gardner. Any violation of

the following may cause termination.

• Arrive clean, neat and appropriately attired.

• If working outside and performing physical labor, jeans or shorts and t-shirts are acceptable.

Volunteers CANNOT wear ripped or torn jeans or shorts. NO biking shorts or boxer shorts.

• Volunteers CANNOT wear halters, low-cut tops, tube tops, tops that show any part of the abdomen,

or revealing clothing of any kind. T-shirts must NOT display pictures, emblems or writings that are

lewd, offensive, vulgar or obscene, or advertise or depict alcoholic beverages or drugs.

• No consumption of alcohol or illegal drugs before or during volunteer work assignment.

• No distribution of literature of any type.

• Visitors are not allowed during volunteer shift.

• No inappropriate behavior with employees, patrons or other volunteers.

• Profanity will not be tolerated while on site.

V. Opportunity

Community Service opportunities include but are not limited to the following: office duties such as filing

and copying, trash pick-up, park beautification, cleaning and physical labors. The City of Gardner

reserves the right to limit the number of Community Service volunteers working within various

departments at any given time.

I affirm that I have read the above and understand the information presented.

Applicant Signature: Date:

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS



1



CriminalOffenderRecordInformation(CORI)

AcknowledgementForm



TobeusedbyorganizationsconductingCORIchecksforemployment,volunteer,subcontr actor,licensing,andhousing

purposes.



_______________________________________________________________________________isregisteredunderthe

 (Organization)

provisionsofM.G.L.c.6,§172toreceiveCORIforthepurposeofscreeningcurrentandotherwisequalifiedprospectiv e

employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of

housing.



Asaprospectiveorcurrentemployee,subcontractor,volunteer,license

applicant,currentlicensee, orapplicantforthe

rentalorleaseofhousing,IunderstandthataCORIcheckwillbesubmittedformypersonalinformation totheDCJIS.I

herebyacknowledgeand providepermissionto__________________________________________________________

 (Organization)

to submit a CORI check for my information to the DCJIS. This authorization

is valid for one year from the date of my

signature.Imaywithdrawthisauthorizationatanytimebyproviding _________________________________________

 (Organization)

withwrittennoticeofmyintenttowithdrawconsenttoaCORIcheck.



FOREMPLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY: 



The_______________________________________________________________________________mayconduct

 (Organization)

subsequentCORI

checkswithinoneyearofthedatethisFormwassignedbyme,provided,however,that

_______________________________________________________________________________,mustfirstprovideme

 (Organization)

withwrittennoticeofthischeck.



By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of

this

AcknowledgementFormistrueand accurate. 



___________________________________________________________ _________________________________

 SignatureofCORISubject Date





The City of Gardner

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS



2



SUBJECTINFORMATION

PleasecompletethissectionusingtheinformationofthepersonwhoseCORIyouarerequesting.

Thefieldsmarkedwithanasterisk(*)arerequiredfields.

 

* FirstName:________________________________________________________ MiddleInitial: _________________



* LastName:_______________ __________________________________________ Suffix(Jr.,Sr.,etc.): _____________



 FormerLastName1: _______________________________________________________________________________



 FormerLastName2: _______________________________________________________________________________



 FormerLastName3: _______________________________________________________________________________



 FormerLastName4: _______________________________________________________________________________



* DateofBirth(MM/DD/YYYY): ___________________ PlaceofBirth:________________________________________



* LastSIXdigitsofSocialSecurityNumber: ______‐‐____________ ☐NoSocialSecurityNumber



 Sex: _________________ Height: _____ft. _____in. EyeColor:_______________ Race: ______________________



 Driver’sLicenseorIDNumber:______________________________________ StateofIssue:____________________



 Father’sFullName: ________________________________________________________________________________



 Mother’sFullName: _______________________________________________________________________________



CurrentAddress



* StreetAddress:____________________________________________________________________________________



 Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________ 



SUBJECTVERIFICATION



Theaboveinformationwasverifiedbyreviewingthefollowingform(s)ofgovernment‐issuedidentification:

__________________________________________________________________________________________________



Verifiedby:



___________________________________________________________

 PrintNameofVerifyingEmployee 



___________________________________________________________ _________________________________

 SignatureofVerifyingEmployee Date

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