The University of Arizona Cooperative Extension, Pinal Co

Pinal County Master Gardener Program

The University of Arizona Cooperative Extension, Pinal Co.

Master Gardener Information Sheet, Terms of Agreement,

Media Release, and Consent to Background Check

I wish to become a University of Arizona Master Gardener volunteer and would like to be accepted in the Pinal County Master Gardener Program. I will be expected to attend all training sessions and commit to a minimum of 50 hours of approved volunteer service to be completed by December 31 of the year following the completion of training. I agree to become familiar with and abide by the Pinal County Master Gardener Policy and Master Gardener Terms of Agreement.

PLEASE PRINT:

Legal Name ______female____male_____

I prefer to use the nickname ______

Home Phone: ______Cell Phone______

Birth date month/day/year______e-mail:______

Mailing Address: ______

City, State, Zip ______

US Citizen ______other ______

Have you ever been employed by University of Arizona? yes ____ no _____

Have you ever been a student at University of Arizona? yes ____ no _____

Please give the name of person who should be notified in case of emergency:

Name ______

Relationship ______

Address ______

Phone ______

VOLUNTEER EXPERIENCE: List volunteer experience in working with community: schools, churches, senior citizens, youth hospitals, half-way houses, etc.

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TRAINING/EDUCATION Please check levels you have achieved:_____ Elementary _____Jr. High

_____ High School _____ Years of College/Areas of Study:______

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WORK STATUS: Please indicate your current work status or expected work status for the coming year.

______Full Time ______Part Time ______Shift Work ______Self-employed ______Student ______Retired

VOLUNTEER STATUS: Please list other volunteer commitments. In addition, is there a time, that you are aware of, when you will not be available for volunteer service during the upcoming year (e.g. job, vacation, snowbird, other commitments)? List dates if known.

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GROUP AFFILIATIONS: Garden clubs, community gardens, plant societies, civic and professional organizations, etc.

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GARDENING AND PLANT-RELATED EXPERIENCE: Please describe your level of experience/training/education related to gardening, botany, soils, plants, agriculture, etc. List any formal courses, certificates, or degrees you have in plant sciences or related sciences.

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TEACHING, PUBLIC SPEAKING, AND OTHER RELATED EXPERIENCE: Please describe any experience you've had teaching, public speaking, working directly with the public, organizing educational events, etc.

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OTHER RELEVANT TRAINING AND EXPERIENCE: Please describe any other training, experience, skills, etc. that you believe would be relevant to you role as a Master Gardener volunteer.

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ADDITIONAL SKILLS, INTERESTS OR EXPERIENCES: We sometimes need special skills or talents to enhance the quality of our volunteer programs. Please check the items below which will add to your effectiveness as a volunteer

_____ Calligraphy_____ Lettering _____ Grant writing

_____ Graphics _____Illustration _____Artwork _____

_____ Writing _____Editing _____ Newsletters

_____ Photography _____ Public relations _____ Marketing

_____ Woodworking ____Related crafts _____ Secretarial, clerical skills

_____ Silk screening _____ Accounting _____Bookkeeping

_____ Video camera operation _____ Editing _____ Computer skills:______

_____ Research _____ Data collection

_____ Other ______

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Why do you want to become a Pinal Cooperative Extension Master Gardener?

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How did you hear about the Master Gardener Volunteer Program?

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Have you ever been a Master Gardener volunteer? ______Yes ______No

If yes, which program and when? Do you plan to continue as a volunteer with the other program?

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TERMS OF AGREEMENT

Upon acceptance into the Master Gardener Volunteer Training Program, volunteers are designated as Associate/Intern Master Gardeners. You are making a commitment to:

1. Complete the Master Gardener volunteer training course. Attendance is mandatory and no more than 3 absences will be excused (makeup's are required for excused absences).

2. Complete the final exam.

3. Complete and document 50 hours of approved volunteer service by December 31st of the year following the completion of training.

4. Maintain a current Volunteer Information sheet and Terms of Agreement on file at the Extension office.

5. Record volunteer hours performed on an approved Extension form.

6. Review and understand the Pinal County Master Gardener Program Policy.

7. Authorize The University of Arizona Cooperative Extension to procure a criminal background report.

8. Maintain a media release on file at the Extension office.

Associates/Interns will become certified master gardeners upon completion of these eight terms.

To remain a Certified Master Gardener Volunteer, each volunteer must:

1. Submit documentation of completion of 25 hours of approved volunteer service each year.

2. Show documentation of 6 hours of approved continuing education hours per year.

3. Maintain signed, current copies of the Volunteer Information Sheet, Terms of Agreement, and a Media Release on file at the Extension office.

There will be no exceptions to these requirements unless stated in the Pinal County Master Gardener Program Policy. It is the responsibility of the volunteer to maintain their credentials appropriately. The master gardener year runs from January 1 to December 31. In order for activities to count toward approved volunteer service, the master Gardener must be identified as a Master Gardener by wearing the approved Pinal County Master Gardener Badge. This badge must be returned to the Extension Office if certification is not maintained annually. If applicable, promotion of events should include reference to the contribution made by Master Gardeners. Hours beyond the minimum requirement may not be carried over to the next year.

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I wish to become a University of Arizona Pinal County Master Gardener volunteer. I understand that I will be expected to attend all training sessions and provide a minimum of 50 hours of approved volunteer service by December 31st of the year following course completion. I further understand that my absence from more than 3 class sessions will result in failure to complete the course. There will be no refund for class fees.

Signature ______Date______

Media Release

From time to time photographs, videos, and/or audio clips may be taken of youth and adults engaging in Cooperative Extension programs and activities.

I grant permission to the Arizona Board of Regents, on behalf of the University of Arizona and its agents or employees, to use photograph, video and/or audio recordings of me for educational purposes These may be used for, but not limited to, promotional brochures, educational and promotional videos including posting on ITunes and/or YouTube, Facebook, web sites, DC, DVD, MP3, MP4, RSS, newsletters, local newspapers and other not-for-profit purposes. I understand these will not be used for commercial gain, but to support the mission of the university of Arizona and Arizona Cooperative Extension.

Signature of Volunteer______Date______

AUTHORIZATION/CONSENT

During the application process and at any time during the tenure of my volunteer service with The

University of Arizona Cooperative Extension, I understand that the University of Arizona may utilize the

services of university-approved vendors as part of the Arizona Cooperative Extension’s screening

procedure for volunteers. I hereby authorize on behalf of The University of Arizona Cooperative Extension

university-approved vendors to procure a criminal background report. This report may be compiled with

information from court record repositories, departments of motor vehicles, past or present employers and

educational institutions, governmental occupational licensing or registration entities, business or personal

references, and any other source required to verify information that I have voluntarily supplied. I understand

that additional criminal background reports may be required from other state or county law enforcement

agencies if university-approved vendors do not provide the required information. I understand that I may

request a complete and accurate disclosure of the nature and scope of the background verification.

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Volunteer Applicant’s Signature Date

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Social Security Number * Date of Birth *

* For identification purposes only

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Printed Name

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Street Address

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City, State, Zip

revised 4/18/17

Issued in furtherance of Cooperative Extension work, acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, James A. Christenson, Director, Cooperative Extension, College of Agriculture and Life Sciences, The University of Arizona.

The University of Arizona is an equal opportunity, affirmative action institution. The University does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, veteran status, or sexual orientation in its programs and activities.