VOLUNTEER APPLICATION

HENDRY COUNTY SHERIFF'S OFFICE

Sheriff Steve Whidden
VOLUNTEER APPLICATION
VIPVOLUNTEERMOUNTED PATROLINTERNSHIPEVENTOTHER
NAME*
DATE OF BIRTH*

MonthDayYear
PLACE OF BIRTH*
Last 4 of SSN*
YesNo
EDUCATION LEVEL
HOME ADDRSS*
CELL PHONE*
Format: (000) 000-0000.
HOME PHONE
Format: (000) 000-0000.
BUSINESS PHONE
Format: (000) 000-0000.
EMAIL ADDRESS*
example@example.com
PLACE OF EMPLOYMENT*
ADDRESS
COMMUNITY/SUBDIV. NAME
OTHER NAME(S) USED
(List Full Names, Dates Used, and Reason for Change in Chronological Order)
YESNO
IF YES, LIST DATE, PLACE, CHARGE, AND DISPOSITION

MonthDayYear
Date
INTERESTS
CERTIFICATES
INTERESTED IN PERFORMING
YESNo
DRIVER'S LICENSE NUMBER*
STATE*
What is your Availability*
How Often
Date

MonthDayYear
VOLUNTEER APPLICATION PAGE 2
EMERGENCY CONTACT NAME*
RELATIONSHIP*
TELEPHONE*
Format: (000) 000-0000.
ADDRESS*
IN THE EVENT OF INJURY REQUIRING MEDICAL ATTENTION IF PERMISSON CANNOT BE READILY OBTAINED FROM MY EMERGENCY CONTACT OR MYSELF, I HEREBY AUTHORIZE THE HENDRY COUNTY SHERIFF'S OFFICE TO PROVIDE SUCH PERMISSION FOR MEDICAL TREATMENT.
VOLUNTEER SIGNATURE:
DATE*

MonthDayYear
APPLICATION MAY BE HAND-DELIVERED OR MAILED TO:

VOLUNTEER SERVICES UNIT - HENDRY COUNTY SHERIFF'S OFFICE

ATTN: Captain Shawn Reed

P.O. BOX 579 LABELLE, FL 33975

(863)674-5600
VOLUNTEER RELEASE FORM
I,*
, for myself, my heirs, executors and administrators, waive and release

any and all rights and claims for damages I may have against the Hendry County Sheriff's Office, its affiliates, officers, agency's employees, and contractors and their representatives and any and all claims of damages, demands, actions whatsoever in any manner, as a result of my participation as a Volunteer with the Hendry County Sheriff's Office. I hereby release and indemnify those parties from any claims for acts of negligence on my part or those affiliated with me. I have read the above release and I understand and agree to the terms.
Signature*

Clear
Date*

MonthDayYear
HENDRY COUNTY SHERIFF'S OFFICE
NOTIFICATION AND USE OF SOCIAL SECURITY NUMBERS
In accordance with the Open Government Sunset Review Act, amending Florida Statute 191.071, the Social Security Number you are providing on this application will be used for the exclusive purposes of conducting a criminal background investigation; gathering and verifying information provided by you to ensure positive identifications; and satisfy requirements for payroll, benefits, and medical leave provided by the Hendry County Sheriff's Office. Your Social Security Number will also be submitted to the Internal Revenue Serivce for tax reporting purposes.
ACKNOWLEDGEMENT: I, *
do solemnly attest that I have read and understand the above Waiver and Notice for Use of my Social Security Number as set forth above.
Signature of Volunteer*

Clear
Date*

MonthDayYear
VOLUNTEER BACKGROUND WAIVER

Fill this section out in person.
I hereby certify that all statements made on this form are true to the best of my knowledge. I understand that I am subject to a background check by the Hendry County Sheriff's Office. I further realize that should an investigation disclose any misrepresentation or ciminal activity, I may be unable to participate in any volunteer capacity with the Hendry County Sheriff's Office.
Signature of Volunteer

Clear
Date

MonthDayYear
Volunteer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AFFIDAVIT
STATE OF FLORIDA, COUNTY OF
Before me personally appeared
, who says that he/she Executed the aboveinstrument of his/her own free will and accord, with full knowledge of the purpose thereof.

Sworn and subscribed in my presence this
day of
,
,
My commission expires on
Personally Known Identification ProducedNotary Public/Law Enforcement Officer Signature
,
Notary Public/Law Enforcement Officer Signature
Type of Identification Produced
Please verify that you are human*
Should be Empty:

HENDRY COUNTY SHERIFF'S OFFICE

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION PAGE 2

VOLUNTEER SIGNATURE:

VOLUNTEER RELEASE FORM

HENDRY COUNTY SHERIFF'S OFFICE

NOTIFICATION AND USE OF SOCIAL SECURITY NUMBERS

VOLUNTEER BACKGROUND WAIVER

AFFIDAVIT