MVP VOLUNTEER APPLICATION

VOLUNTEER APPLICATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
License #*
State of License*
Availability- Days/Frequency*
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
References
Reference #1 Name*
Phone Number*
Reference #2 Name
Phone Number
Reference #3 Name
Phone Number
Insurance Information
Insurance Company*
Insurance Phone Number*
Policy #*
Signature*

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Volunteer Expectations:

• Use personal vehicle in safe working condition

• Maintain valid driver’s license and insurance as required by Missouri law • Follow the delivery schedule and safety procedures

• Report any incidents or accidents immediately

Acknowledgments:

I understand and agree that:

• I am volunteering my time and services without compensation.

• I will not be considered an employee or agent of the City of Excelsior Springs. • I am using my personal vehicle for deliveries and am solely responsible for any accidents, damage, or injuries that may occur during such use.

• I maintain auto liability insurance that meets or exceeds Missouri’s minimum requirements.

• By signing below, I agree to release and forever discharge the City of Excelsior Springs—including its officials, employees, agents, and volunteers—from all claims or legal actions for injuries, losses, or damages I may experience while volunteering for the Homebound Meal Delivery Program. This includes anything that happens while I’m driving my own vehicle or helping with meal prep or delivery. I also agree not to sue the City or its employees for any injury or damage caused by their ordinary negligence while I am participating in this program. This waiver does not cover situations where the City or its employees act with intentional harm or extreme carelessness (gross negligence)
Signature*

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Date

MonthDayYear
Date

Information Confirmed Below
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact

First NameLast Name
License #
Policy #
Relationship
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date

AGREEMENT AND CONSENT TO

DRUG AND/OR ALCOHOL TESTING

I understand that the City of Excelsior Springs requires drug testing as a part of its selection and hiring process and is required of all applicants selected for employment. I further understand that if such testing indicates the presence of illegal drugs in my body in detectable amounts, I will be disqualified from further hiring consideration. I understand that refusal to consent to and participate in such drug testing will automatically disqualify me from further hiring consideration. I hereby give my consent any or all drug testing procedures, and to use the results of such testing in further determining my employability with the City of Excelsior Springs.

I hereby further agree that as an employee of the City of Excelsior Springs, I will submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis upon a request made under the drug/alcohol testing policy of City of Excelsior Springs. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under City policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have the City of Excelsior Springs and/or its

physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the City of Excelsior Springs and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the City of Excelsior Springs to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized City officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless the City of Excelsior Springs, its company physician, and any testing laboratory the Company might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as result of the drug or alcohol lest, even if the City of Excelsior Springs or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. l will further hold harmless the City of Excelsior Springs, its physician, and any testing laboratory the City might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I UNDERSTAND THAT THE CITY OF EXCELSIOR SPRINGS WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT, UPON REASONABLE SUSPICION THAT DRUG OR ALCHOL USE IS ADVERSLEY AFFECTING MY JOB PERFORMANCE, OR BY UNANNOUNCED RANDOM

SELECTION, AND I AGREE TO SUBMIT TO ANY SUCH TEST.
Signature*

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Name*

First NameLast Name

DISCLOSURE AND AUTHORIZATION [IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION
City of Excelsior Springs (“the Company") may obtain information about you for employment purposes from a third party consumer reporting agency. Thus; you may be the subject of a “consumer report" and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics1 and/or mode of living, and which can involve personal interviews with sources such as your neighbors; friends, or associates. These reports may contain information regarding your credit history, criminal history, social security number validation, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks, Credit history· will Only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time1 to request whether a consumer report has been requested and compiled about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Validity Screening Solutions, PO Box 850443, Shawnee, KS 56286-0443, 866.915.0792, www.validityscreening.com, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by EMPLOYER by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.
New York and Maine applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by EMPLOYER, and is such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.
Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage of disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request.
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents, l hereby authorize the obtaining of “consumer reports'' and/or "investigative consumer reports" by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university {public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Validity Screening Solutions, PO Sox 860443, Shawnee, KS 66286-0443, 866.915.0792, www.validityscreening.com, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. 🗆 Must include email address: __________________________________________
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

www.validityscreening.com/Site/PrivacyPolicy 🗆 Must include email address: __________________________________________
Name*

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Signature*

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Date

MonthDayYear
Date
Email
example@example.com
License #
Phone Number
Please enter a valid phone number.
Should be Empty:

VOLUNTEER APPLICATION

Emergency Contact

References

Insurance Information

Information Confirmed Below

DISCLOSURE AND AUTHORIZATION [IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION