Douglas A. Ducey
Lisa A. Atkins
Governor
Commissioner
VOLUNTEER REGISTRATION FORM
This portion of the form is to be completed by the Volunteer: (Please print)
VOLUNTEER’S NAME: __________________________________________________
CELL #( )
MAILING ADDRESS: ______________________________ HOME #(___)__________
LIABILITY COVERAGE: Volunteers are persons doing State of Arizona work / activities under the
direction and control of a State authorized official and are not being paid.
Liability coverage is extended to volunteers acting at the direction of a State official and within the course
and scope of their State authorized activities. Volunteers of the State are provided the same liability
protection afforded employees. Thus, volunteers acting within the course and scope of their State
authorized activities may be covered for their liability exposure as authorized volunteers of the State.
WORKERS’ COMPENSATION IS NOT COVERED: Volunteers are NOT covered by the State’s workers’
compensation plan if injured while participating in this program (except for volunteers covered pursuant to
A.R.S. 23-901). Volunteers are strongly encouraged to obtain their own medical insurance before
participating in this program. When there is no other insurance in place, Risk Management has a
purchased volunteer accident medical and AD&D program. Claim forms can be obtained from the Risk
Management web site at “www.azrisk.state.az.us”.
Do you have health insurance? Yes ___ No ___ If yes, please provide the following information:
Name of Medical Insurance Carrier: _______________________________________________________
Policy # _____________________________________________________________________________
I have carefully read the above information and understand its contents. The above information provided
by me is accurate.
VOLUNTEER’S SIGNATURE DATE
This portion of the form is to be completed by the Supervisor: (Please print)
SUPERVISOR’S NAME TITLE TELEPHONE #
DEPARTMENT DUTIES OF VOLUNTEER BEGIN / END DATE
VEHICLE INFORMATION YES NO
Will the volunteer be driving a State owned or rented vehicle or an 8- to 15-passenger van?
Does the volunteer have a valid driver’s license?
Have you checked the volunteers Motor Vehicle Record?
If yes, has the volunteer successfully completed the mandatory 15 passenger van training course and
been certified?
Expiration Date of Certification Card:
Does the volunteer have previous experience driving a 15-passenger van?
IF YES, DESCRIBE:
SUPERVISOR’S SIGNATURE DATE
DISTRIBUTION LIST: (1) Agency Personnel Department, (2) Supervisor, (3) Volunteer
Natural Resources Division
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