76 N. Main Kanab, Utah 84741 Phone(435)644-3696 Fax(435)644-4996
Revised 1/14
(Ms.) (Mrs.) (Mr.) Email Mailing Address City Zip
Phone Cell Phone Date of Birth / /
Best way(s) to reach you: Cell Phone [ ] Texting [ ] Home Phone [ ] Email [ ]
Do you drive? YES [ ] NO [ ] Drivers License # Exp. ______State______
Will you be driving to volunteer sites or assignments? YES [ ] NO [ ]
* If yes the automobile you will be driving must have liability insurance.
Do you have Automobile Liability Insurance? YES [ ] NO [ ] Provider
Have you been convicted of a felony? YES [ ] NO [ ]
Are you a registered sex offender? YES [ ] NO [ ]
Physical limitations to be considered in making volunteer assignments
Current or previous work or occupation
Education, skills and/or special training General interests or hobbies
Previous or current volunteer service
When are you available for volunteer service? (Check all that apply)
Weekdays[ ]Weekends[ ]As needed[ ]
Daytime[ ]Evenings[ ]
Please indicate the age group you wish to work with (check all that apply)
Children[ ]Teenagers[ ]Frail, elderly[ ]
Adults[ ]Disabled[ ]No preference[ ]
Person to notify in an emergency Telephone Relationship to volunteer
DISCLAIMER: While in service as a volunteer, I agree to hold Kane County, Volunteer Center and/or the Retired Volunteer Program harmless in the event of personal injury or liability. I also agree to maintain the minimum limit of automobile liability insurance required by the State of Utah, if a personal automobile is used in service activity. I understand a background check will be performed and I authorize a release of my criminal history record to this agency to accompany my volunteer application. Any information discovered will be used to consider my suitability for the purpose of my application.
I understand that the Volunteer ID badge that I am issued is the property of the Kane County Volunteer Center and will be returned upon separation with this agency.
APPLICANT SIGNATURE Date
------
FOR OFFICE USE ONLY
Volunteer Station or Event______
ID Badge Given on ______Returned on ______
Criminal History
Dispatch Name ______Date______
SKILLS LIST
Please check your skills, interests, talents and abilities according to your interest, as follows:
I Have knowledge of or would like to volunteer in this area.
AGRICULTURE/ENVIRONMENT
[ ] Agriculture
[ ] Ecology
[ ] Landscaping
CLERICAL/OFFICE
[ ] Clerical
[ ] Computer Skills
[ ] Web Page Design and or
Management
[ ] Sales
COMMUNICATIONS
[ ] Advertising
[ ] Marketing
[ ] Audio-visual
[ ] Writing
[ ] Telephone skills
COMMUNITY
[ ] Crisis Intervention
[ ] Events Planning
[ ] Tourism/Information
CRAFTS
[ ] Arts and Crafts
[ ] Ceramics
[ ] Sewing
[ ] Toy making
[ ] Woodworking
DOMESTIC
[ ] Baking
[ ] Canning/Freezing
[ ] Housecleaning
[ ] Personal Grooming
EDUCATION
[ ] Preschool
[ ] Elementary Education
[ ] Secondary Education
[ ] Special Education
[ ] Tutoring
EMERGENCY
[ ] Disaster Preparedness
[ ] Fire Safety
[ ] Flood
[ ] Emergency Medicine
HEALTH / MEDICAL
[ ] CPR Trained
[ ] Dentistry
[ ] Disabled
[ ] First Aid
[ ] Geriatrics
[ ] Home Health Care
[ ] Mental Health
[ ] Nursing
[ ] Paramedic
[ ] Physician
HUMAN SERVICES
[ ] Child/Women's Abuse
[ ] Counseling
[ ] Hospice
[ ] People w/Disabilities
[ ] Senior Companions
[ ] Single Parent Support
[ ] Transportation
LANGUAGES
[ ] French
[ ] German
[ ] Japanese
[ ] Portuguese
[ ] Russian
[ ] Spanish
MAINTENANCE
[ ] Auto Mechanics
[ ] Carpenter
[ ] Construction
[ ] Electrician
[ ] Plumber
SPORTS / RECREATION
[ ] Baseball
[ ] Basketball
[ ] Bowling
[ ] Bridge
[ ] Coaching
[ ] Cycling
[ ] Golf
[ ] Gymnastics
[ ] Horseshoes
[ ] Lawn Bowling
[ ] Lifesaving Tech.
[ ] Mountain Biking
[ ] Racquetball
[ ] Road Racing
[ ] Soccer
[ ] Softball
[ ] Special Olympics
[ ] Square Dancing
[ ] Swimming
[ ] Table Tennis
[ ] Tennis
[ ] Track & Field
[ ] Tri-athlon
[ ] Volleyball
OTHER
[ ] Fund Raising
[ ] Board Participation
[ ] Grant Writing