Fillable Volunteer Application Applicants Name Complete Address Phone Email (City of Dallas)

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Volunteer Application Applicants Name Complete Address Phone Email (City of Dallas)

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Volunteer
Application
In what department are you interested in volunteering?
Relationship
Personal Reference’s Name
Phone
Relationship
Official Use Only
Date
Dept Assigned
Applicant’s Name
Complete Address
Phone
Date of Birth (some positions require a minimum age)
Driver License Number and State
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning
Afternoon
Evening
Aquatic Center
City Manager's Office
Finance
Planning & Building
Police
Public Works
Fire
Library
Parks
Professional or Volunteer Reference’s Name
PhonePho
Email
Please describe any skills and experience you have through employment, previous volunteer
work, or other activities (such as hobbies). Example: Typing or lifeguarding.
Form # 2
Last Revised: 09/22/2020
File Location: I:ALL/City Forms
Emergency Contact’s Name
Phone
Relationship
I hereby certify that this application contains no misrepresentations or falsifications and that the
information given is true and complete to the best of my knowledge and belief. I authorize the
City of Dallas to make any necessary and appropriate investigations to verify the information I
provide in my application and to investigate my personal, professional, and financial credit
background, including any criminal records and past employment records. I also release the
City of Dallas and any persons, companies, or corporations supplying the above information
from all liability pertaining to information concerning my background.
I acknowledge that the City of Dallas will not provide health or accident insurance for my
benefit and that I am responsible for providing my own health or accident insurance. I further
acknowledge that I am not entitled to and will not receive any employment or workers’
compensation benefits from the City of Dallas. I understand and agree that I or my estate will
be responsible to pay any and all costs incurred as a result of injury, illness, or death suffered
while participating as a volunteer or intern. This acknowledgment and agreement will be
binding on me and my heirs, personal representatives and successors.
Completing this form is not a guarantee of placement. I understand that as a volunteer, I am not
an employee of the City of Dallas and that any duties I perform are as a volunteer. I agree to
follow the procedures and guidelines set forth by the City of Dallas for my assigned work duties.
Signature Date
If you are under 18 years of age, your parent or guardian must complete the following:
I give my permission for my child/ward to volunteer for the City of Dallas.
Signature of Parent/Guardian Date
Have you ever been convicted of a crime? Yes No
If yes, please explain below. Exclude cases processed in juvenile court and minor traffic
violations. Conviction does not necessarily disqualify you from a volunteer position.
City Manager's Office
187 SE Court Street
Dallas, OR 97338
503-831-3502
sam.kaufmann@dallasor.gov
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Volunteer Application Applicants Name Complete Address Phone Email (City of Dallas)

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Completed 22 January 2021

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