University of Nevada Cooperative Extension (UNCE)

University of Nevada Cooperative Extension (UNCE)

Adult Volunteer working with Youth background information and application

Name

First Middle Last

Mailing Address

Street City Zip

Length of time at above address County Phone Day Evening

Emergency Contact

Name and number

DOB Drivers’ License # Social Security #

mm/dd/yy

Have you ever been convicted of a criminal offense? Yes ( ) No ( )

If yes, please give date, nature of offense, and disposition.

References: List three persons, not related to you, who have knowledge of your qualifications to work in youth development programs. UNCE must have complete addresses.

(1) Name Mailing Address

Phone ( )

(2) Name Mailing Address

Phone ( )

(3) Name Mailing Address

Phone ( )

I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment as a volunteer. If appointed as a volunteer, I agree to abide by the policies of UNCE youth development programs. By signing below, I , hereby voluntarily authorize the University of Nevada Cooperative Extension to obtain references about me from the sources provided herein, or any other sources as deemed necessary, and to consider the references when making decisions regarding my status as a volunteer with the University of Nevada Cooperative Extension. I also understand that my appointment as a volunteer is contingent on passing the background check. I voluntarily authorize the University of Nevada Cooperative Extension to utilize this release of information/references document at their discretion. I release and hold harmless each and every person, company, or other party that may provide the aforementioned reference to the University of Nevada Cooperative Extension. I further release and hold harmless any employee, officer, or volunteer of the University of Nevada Cooperative Extension who may utilize this information to determine my eligibility as a volunteer or who may have access to this information.

Signature Date

Effective May 12, 1999, Revised September 2005

Are you a 4-H alumni? Where were you in 4-H?

Have you previously been a 4-H leader? Yes NO

If yes, how many years? Where?

Town County State

Do you prefer to work directly with ( ) youth ( ) adults ( ) both

If you prefer to work directly with youth, what age level(s) do you prefer?

( ) Pre-4-H age ( ) 12-14 years

( ) 9-11 years ( ) 15-19 years

What time commitment do you desire initially?

( ) 1-3 months ( )3-6 months ( ) 6-12 months

Are you available to volunteer? Mornings Afternoons Evenings Weekends

Previous Volunteer Experience: (List current or most recent experience first)

Organization Position Title or Major Responsibilities From mo/yr to mo/yr

Skills, Training, or Education related to working with youth: (describe)

Community Organizations/activities: (describe)

Hobbies, Skills, and Interests that can be shared with youth in 4-H: