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First Name*: |
Last Name*:
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Address*: |
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City*: |
State*:
"Zip*:
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Primary Telephone* - Area Code: |
Number:
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Secondary Telephone - Area Code: |
Number: |
Email Address: |
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Emergency Contact - First Name*: |
Last Name*: |
Address: |
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City: |
State: Zip: |
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Emergency Contact Phone* - Area Code: |
Number:
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CPR Certified? |
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AED/Heartsaver Certified? |
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Are you at least 18 yrs. old? |
Yes
No |
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If not, please enter your birthdate:
(mm-dd-yyyy) |
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| Special Skills, Certifications, Training: |
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Other Relevant Information: |
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Available Day(s) to volunteer: |
Mon.
Tue.
Wed.
Thu.
Fri.
Sat.
Sun.
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Available Time(s) to volunteer: |
A.M.
P.M.
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| I live in the following geographic location: |
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I am interested in the following types of volunteer opportunities: |
Special Eventsl/Recreation Events
Emergency/Recovery Efforts
Office Assistance
Children's Activities(i.e., summer camp, coaching, etc.)
Other (Please specify)
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I understand that volunteer opportunities may require a criminal background check, references, a physical exam, and/or a
drug screen, and I am willing to submit to the screening process required for the particular volunteer opportunity. |
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I understand that as a City volunteer, I am not entitled to compensation for my service. |
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I hereby release and hold harmless the City of Coconut Creek, its officers and employees from any and all
causes of action I may have arising from my activities as a volunteer for the City of Coconut Creek. |
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I understand that if I am injured in any way while acting in a volunteer capacity, I must report the injury immediately
to the on-site supervisor, and I must follow procedures as instructed to be covered by Workers' Compensation. |
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I certify that all information provided on this application is accurate, and I understand that false statements may
disqualify me from consideration for volunteer opportunities. |
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