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DUCHESNE COUNTY VOLUNTEER APPLICATION FORM

Contact and Personal Details
What are you Volunteering For?*

FairCitizen's AcademyOther
Please Describe
Date

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Date
Name*
Address*
City*
State*
Zip*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Number*
If you anticipate operating a motor vehicle for and in behalf of Duchesne County while acting as a volunteer for the Duchesne County Fair, please fill out the Driver’s License Information below.
Driver’s License Number
State Issued
Expires

Volunteer Verifications
Please specify the activities and functions you will be volunteering:
Citizen's Academy can just put "Citizen's Academy"
You acknowledge that if your application is approved, you will be considered a “volunteer” according to Utah Code Annotated 67-20-1 et. seq. As a volunteer government worker, you receive liability protection and indemnification (reimbursement for legal fees and costs) normally afforded a government employee. Your exclusive remedy for personal injury or occupational diseases will be workers’ compensation medical benefits.

By making this application, I hereby authorize Duchesne County to perform criminal history background checks, or to obtain any other information of whatever kind in either written or verbal form which relates to my ability to perform the duties of the volunteer position for which I am applying. I release Duchesne County of any liability for the use of this information in considering and reviewing my application.
I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND COMPLETE, AND THAT ANY MISSTATEMENT OR OMISSION OF MATERIAL FACTS MAY SUBJECT ME TO DISQUALIFICATION OR DISMISSAL*

I HAVE READ AND SIGNED THE SEXUAL HARASSMENT POLICY
VOLUNTEER SIGNATURE
Signature*

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Date

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Date
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Agreement