Contact Name
Street Address
City, State, Zip Code
Phone Number
Email Address
Area(s) of Interest
Pertinent Skills / Experience
Days and Hours Available for Volunteer Work
Driver's License Number
Have you ever been convicted of a felony?Yes
No
By submitting this form, I authorize my former employers and school authorities to give any information regarding my employment, together with any information they may have regarding me whether or not it is on their records. I authorize the City of Portage to conduct a criminal record investigation and driving record investigation. I hereby release them and their organization from any damage whatsoever for issuing same. I understand this is not a compensatory position, nor a promise of one. Furthermore, I understand that as a volunteer, I am not able to collect benefits including, but not limited to, Workers' Compensation. I acknowledge that I am volunteering my time and when this arrangement is no longer desirable by either party, either the City of Portage or myself may terminate this relationship.
Applicant's Signature (eSign by typing name)