INDIVIDUAL VOLUNTEER APPLICATION
Appendix III
New York State Department of Environmental Conservation
Volunteer Stewardship Agreement (VSA)
A. Applicant Information Stewardship Agreement Number
Name: (First, MI, Last)
Telephone:
(Home/Cell)
Address: (No. and Street)
Email Address:
City, State, Zip Code:
B. If a volunteer is working with minors or will be driving to perform activities as outlined in the Stewardship Agreement
they must fill out the questions below about criminal convictions. All other volunteers may skip Section B.
Have you ever been convicted of any crime (felony or misdemeanor)?
☐ Yes ☐ No
Are you currently under charges for any crime?
☐ Yes ☐ No
If you answered “yes” to either of the above questions, please explain in Section F below or attach a separate sheet. None of
the above circumstances represents an automatic bar to volunteer for work. Each case is considered and evaluated on
individual merits in relation to the duties and responsibilities of the position(s) for which you are applying.
C. Emergency Contact:
Name: _______________________________ Daytime Telephone Number ___________________________________
D. Are You Under 18 Years of Age? (If yes, a parent or
guardian must sign below.)
☐Yes
☐No
Date of Birth:
(mm/dd/yy)
PARENT/GUARDIAN PERMISSION (Only if Volunteer is under 18 years of age)
Print Name:
Signature:
Relationship to Volunteer: ____________________________ Date:
______________
I certify that the answers on this Volunteer form are correct to the best of my knowledge and belief and that a false statement
knowingly made may be considered cause for termination of volunteer service.
Volunteer’s Signature:
_________________________________________________
Date:
________________
¾ The Steward initiator must verify the volunteer’s identity before signing and submitting this application to the
Department.
¾ A photocopy of the volunteer’s driver license must be attached to this application if the volunteer will be driving a state
or personal vehicle to perform activities as outlined in the Stewardship Agreement.
E. Stewardship Agreement Name:
Initiated by: (individuals authorized in the Stewardship Agreement)
Signature: _________________________________________ Date ______________________
DEC Respective Management Authority or his/her designee
Signature __________________________________________ Date ______________________
F. Remarks or additional information:
☐
Additional information attached
