Chattahoochee Valley Citizen’s Corps

Volunteer Form (Please Print)

Name: ______Soc. Sec. # ______

Address: ______

Street City State Zip

Email Address: ______Driver License #______

Home Phone: ______Work Phone: ______Cell Phone: ______

Place of Employment: ______Shirt Size: ______

Occupation: ______Full Time _____ Part Time

_____ Retired _____ Student

U.S. Citizen? ______Yes ______No

Please list areas of Licensure/Certification: ______

______

State(s) where you are Licensed: ______

Other Training, Specialty, or Experience: ______

Please list other Volunteer Affiliations: ______

______

Military Experience: Yes/No If yes, explain: ______

Have you ever been convicted of a crime? Yes/No If yes, date: ______

If yes, can you explain: ______

Emergency Contact Information:

Name: ______

Last First MI

Home Address: ______

Street City State Zip

Relationship: ______

Home Phone: ______Work Phone: ______

Once you have had the opportunity to go through the CERT program as the primary training core competency of the Chattahoochee Valley Citizen’s Corps and have had orientation with other affiliated volunteer programs under the local Citizen’s Corps, which program do you want to be listed as a primary member:

CERT _____

CLEA_____

MRC_____

Neighborhood Watch_____

Other_____

I hereby certify that all the information on page one is accurate and correct and I hereby make application for membership in the Chattahoochee Valley Citizen’s Corps. By signing below, I am expressing interest in volunteering to assist with unforeseen disasters affecting the bi-area. I understand I am not obligated to participate in these events. I also understand that I will be informed of any training and educational sessions pertaining to the volunteer programs offered under the Chattahoocee Valley Citizen’s Corps umbrella. I agree to have the information provided entered into a database so that I may be contacted for training opportunities and volunteering.

I understand that I am applying for a volunteer position and this is not an application for, or a contract of, employment.

______

Signature Date

I understand that every attempt will be made to reduce risks to volunteer, however, some risks may be present during a public health emergency and I agree to assume my own risk as a volunteer.

______

Signature of Applicant Date

PHOTO PERMISSION:

Yes, ______, I give my permission to be interviewed and/or photographed for publicity purposes. I understand that this information may appear publicly in a newspaper or other advertising media. No expiration on this permission unless notified.

______

Signature Date

BACKGROUND CHECK:

The Chattahoochee Valley Citizen’s Corps Council may require you to undergo a background check depending on your role as a volunteer. This is done for safety and security concerns of all citizens of the bi-area and is not meant to be an intrusion.

_____ Yes, I agree to have my background checked.

CREDENTIALS VERIFIED:

I give my permission to have my credentials verified.

______

Signature Date

______

For Office Use Only:

Credentials Verified ______Date______

______

Please return completed application to: Tamber Fuller

Columbus Department of Public Health

2100 Comer Avenue

Columbus, Georgia 31904

Fax # 706-321-6155

Or

Rick Kelly
Muscogee County Sheriff's Office
Training Section


Office: 706-653-4220

Or

Jan Boswell, Russell County AL EMA

311 Prentiss Drive

Phenix City, Alabama 36869

Chattahoochee Valley Citizen’s Corps

Code of Conduct

All volunteers of the Chattahoochee Valley Citizen’s Corps in delivering volunteer services and in all other volunteer activities shall meet the following standards of conduct.

No volunteer shall:

  1. Authorize the use of or use for the benefit or advantage of any person, the name, emblem, endorsement, services, or property of the Chattahoochee Valley Citizens’ Corps and/or it’s volunteer organizations.
  1. Accept or seek on behalf of any person, any financial advantage or gain of other than nominal value offered as a result of the Volunteer or staff member’s affiliation with the Chattahoochee Valley Citizen’s Corps.
  1. Publicly utilize any Chattahoochee Valley Citizen’s Corps affiliation in connection with the promotion of partisan politic, religious matters, or position on any issue not in conformity with official position of the Chattahoochee Valley Citizen’s Corps and/or it’s volunteer organizations.
  1. Disclose any confidential Chattahoochee Valley Citizen’s Corps and/or it’s volunteer organizations’ information that is available solely as a result of the volunteer of staff members affiliation with the Chattahoochee Valley Citizen’s Corps to any person not authorized to receive such information or use to the disadvantage of the Chattahoochee Valley Citizen’s Corps and/or it’s volunteer organizations any such confidential information, without express authorization of the Chattahoochee Valley Citizen’s Corps.
  1. Knowingly take any action or make any statement intended to influence the conduct of the Chattahoochee Valley Citizen’s Corps and/or it’s volunteer organizations in such a way as to confer any financial benefit on any person, corporation, or entity in which the individual has significant interest or affiliation.
  1. Operate or act in any manner that is contrary to the best interest of the Chattahoochee Valley Citizen’s Corps and/or it’s volunteer organizations.
  1. No Volunteer shall self-deploy.

10/2008

Chattahoochee Valley Citizen’s Corps
Code of Conduct
Certification

I, ______, a volunteer for the Chattahoochee Valley Citizen’s Corps have read and understand the Code of Conduct of the Chattahoochee Valley Citizen’s Corps and agree to comply with the code as it is set forth in the attached document.

Signature

______

Date