Name Maiden/Other Names:
Address City State Zip
Home Phone Work Phone E-Mail Address
Driver’s License Number State Expiration
Gender Date of Birth Race
Parent’s Names (IF APPLICANT UNDER 18)___________________________________________________ Phone_______________________
Contact In Case of Emergency:
(Name) (Relationship) (Phone)
Personal or Professional References (Please Exclude Relatives)
1. Name Relationship Phone
Address City State _________Zip
2. Name Relationship Phone
Address City State Zip
Have you ever been convicted of a crime, other than a minor traffic offence? Yes No If yes, please explain below:
Please list any skills, foreign languages, hobbies, or interests you have that might be helpful in your volunteer work:
Availability: Mon. Tues. Weds. Thur. Fri. Sat. Sun.
Office Use Only
PSOR __________________________ Date____________________
Criminal Records _________________ Date ____________________
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Applicants Authorization & Agreement
(Please read the following carefully before signing)
I hereby certify that all statements on this application are made truthfully, and further understand and agree that such
statements may be investigated and if found to be false will be sufficient reason for not being accepted as a volunteer, or if
accepted may result in my dismissal.
I authorize the City of Wyoming to secure additional relevant information from my employer, prior employer, educational
institution or any other persons or organizations concerning my employment, education, disciplinary information or any other
relevant information, personal or otherwise, and release all parties from all liability for any damage that may result from
furnishing this information to the City of Wyoming.
In accordance with A.D.A. requirements, if I require special accommodations to perform my services, I must notify the
Wyoming Parks and Recreation Department of that need within 182 days after I knew or reasonably should have known that
special accommodations were needed. Failure to do so will bar me from alleging that the City of Wyoming has not
accommodated me as required by law.
I hereby authorize the City of Wyoming to secure a criminal conviction history from the appropriate law enforcement agencies,
should the City determine it necessary to do so. In addition, I will furnish the necessary identification for such an investigation
to take place.
I hereby grant the City of Wyoming permission to use and display my likeness in photographs(s)/video in any publication,
multimedia production, display, advertisement or World-Wide Web publication for Wyoming Parks and Recreation or its
constituent departments.
I agree to abide by all program rules and regulations set forth by the Wyoming Parks and Recreation Department. I understand
that my volunteer services may be terminated at any time by that department. I also understand that there are certain inherent
risks involved in any activity. I hereby release, discharge and hold harmless the City of Wyoming and its officers, employees,
volunteers, contributing sponsors and affiliate organizations from any and all liability for any physical or mental injury or
aggravation of any pre-existing condition, illness or disability, death, loss of enjoyment or any other harm or loss of any nature
which may be sustained by me while serving as a volunteer for the Wyoming Parks and Recreation Department.
Please print name with one letter in each box.
First Name Last Name
Applicant’s Signature
Please print name with one letter in each box.
First Name Last Name
Parent’s Signature (If Applicant Under 18)
*Your signature indicates your approval for your child’s participation as a volunteer in this program.
If you have any questions or concerns regarding this application, please call our office at (616) 530-3164.
The Wyoming Parks and Recreation Department promotes a non-discrimination policy that ensures participation for all
regardless of race, religion, sex, economic status or disability.
(Please enter your name for use as your signature)
(If needed please enter your name for use as your signature)
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