Senior Programs Volunteer Application 2024

Senior Programs Volunteer Application

City of Claremont - Human Services Department
Senior Program participants and staff thrive when volunteers are committed and perform in routine positions and duties. I am open to committing to a routine assignment for a minimum of four months*
Initial

APPLICANT INFORMATION
Name*

First NameLast Name
MI
Today's Date

MonthDayYear
Date
Address*

Street Address

Apartment / Unit #

CityState / Province

Postal / Zip Code
Date of Birth - Must be 18+ to participate.*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Please list any languages spoken other than English.
Have you ever worked or volunteered for the City of Claremont?

YesNo
If so when

EDUCATION
High School
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YesNo
Degree
College
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YesNo
Degree
Other Education
Address
From

MonthDayYear
Date
To

MonthDayYear
Date
Did you graduate?

YesNo
Degree

REFERENCES
Reference 1
Full Name*
Relationship*
Company
Phone*
Address
Reference 2
Full Name*
Relationship*
Company
Phone*
Address

VOLUNTEER INTERESTS
Please mark the areas you would be interested in volunteering with.*

Special EventsNutrition Program / Food ServicePhone Assurance Line (PAL) CallsTech Assistance and Computer Lab with the Claremont Senior Computer ClubInstructor or Group/Activity Leader

EMPLOYMENT HISTORY
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title
Responsibilities
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May we contact your previous supervisor for a reference?

YesNo
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title
Responsibilities
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May we contact your previous supervisor for a reference?

YesNo

SUPPLEMENTAL INFORMATION AND QUESTIONS
Please list any training certifications or experience not listed above that you feel qualify you for this role.
Please add additional information about yourself, hobbies, community interests, clubs, etc.
Please list your availability by day of the week If you have any significant commitments for which you do not yet have times such as attending school next semester please list this as well.

WAIVER, RELEASE, HOLD HARMLESS, AND AGREEMENT NOT TO SUE:
I understand and acknowledge that, although the City of Claremont takes measures to ensure participants' safety, there are inherent risks associated with the above-referenced activity/event, such as property damage, injury, illness, and death. To the extent permitted by law, I - on behalf of myself, my heirs, and my personal representatives, and on behalf of any minor children listed above - hereby agree to release, indemnify, defend and hold harmless the City of Claremont and its officials, officers, employees, contractors, volunteers, and agents from and against any and all liabilities, claims, penalties, losses, or expenses (including attorneys' fees), of any kind or nature whatsoever, whether related to bodily injury, property damage, or any other form of injury or loss, caused by any negligent act or omission of the City of Claremont or its officials, officers, employees, contractors, volunteers, and agents, arising out of or in any way related to the activity/event.

In particular, I understand and acknowledge the contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that the City of Claremont has put in place preventative measures to reduce the spread of COVID-19, but the City cannot guarantee that participants will not become infected with COVID-19 as a result of their attendance at this activity or event. I understand and acknowledge the risk of being exposed to and/or infected by COVID-19 as a result of attending this activity or event. Knowing this risk, and/or the children listed above voluntarily agree to attend the activity or event. I agree to comply with all federal, state, and local laws, health orders, guidelines, and procedures that aim to reduce the spread of COVID-19 during this activity/event. If I observe any unusual or significant hazard during the activity/event, I will take immediate precautions to ensure my safety (such as leaving the activity or event, if necessary) and immediately bring the hazard to the attention of the City Human Services staff or the City's Police Department.

I hereby authorize the City of Claremont to call for emergency assistance (including an ambulance) in case of accident or acute illness, and to arrange for necessary medical or surgical care for me/any child listed above in the event that the emergency contact person(s) designated are unavailable. I understand that a conscientious effort will be made to notify me or the emergency contact person designated at the time of enrollment before such action is taken. I am participating/allowing any children listed above to participate at my own risk. I understand and agree that, as a participant in this activity/event, I and any children listed above may be photographed, and I agree that the City may use such photographs for City purposes (such as to publicize City activities/events) without compensation and without further permission.

I certify that I have read and understand this waiver and release. I certify that I have capacity to sign this contract for any minor children listed above (i.e., am their parent, legal guardian, or I have authorization from their parent or legal guardian to contract on their behalf By signing below, I am accepting these risks and responsibilities for myself and for any children listed above.
Signature*

Clear
Date

MonthDayYear
Date

CERTIFICATE OF APPLICANT
"I certify that all statements made in this application and attachments are true and complete to the best of my knowledge. I authorize the City of Claremont to make investigations and inquiries that are limited to the requirements for this position, of my employment, financial and medical history and other related matters, as they relate to the requirements of the position for which I am applying. In arriving at an employment decision, I hereby release employers, schools or persons from any liability in responding to inquiries in connection with my application. I understand that any false or misleading information given in my application or any step in the employment selection process will subject me to disqualification or dismissal. I understand also that I am required to abide by all rules and regulations of the City of Claremont."
Signature*

Clear
Date

MonthDayYear
Date

DISCRIMINATION AND/OR HARASSMENT POLICY
ACKNOWLEDGEMENT OF RECEIPT OF DISCRIMINATION AND/OR HARASSMENT POLICY
Position: *

Volunteer
This will acknowledge that I have received my copy of the City of Claremont Discrimination and/or Harassment Policy (“Policy”) and that I have read the Policy and understand my rights and obligations under the Policy.

I understand that this Policy represents only current policies, procedures, rights, and obligations and does not create a contract of employment. Regardless of what the Policy states or provides, the City retains the right to add, change, or delete provisions of the Policy and all other working terms and conditions without obtaining another person’s consent or agreement.

My signature below further signifies that I have read this Policy and that I accept and will abide by all of its provisions.
Full Name*
Signature*

Clear
Date

MonthDayYear
Date

SUBMIT
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Senior Programs Volunteer Application

ACKNOWLEDGEMENT OF RECEIPT OF DISCRIMINATION AND/OR HARASSMENT POLICY