Volunteer Connection Services Form
Instructions: Please complete and submit your form below.If you have trouble filling out this form, please visit Human Resources at 240 Water Street, Henderson, NV 89015 or call 702-267-1940
How did you hear about The Volunteer Connection?
Street Address and Unit # (if applicable)
City, State, Zip
Work Phone or Cell Phone
Emergency Contact (name, relationship, phone number)
Have you ever been arrested or convicted of any crime?
(If yes, please explain, in detail, arrests, convictions, etc.)
Do you have previous Law Enforcement Experience?
(If yes, how many years, and in what capacity?)
Volunteer Experience and Availability
Are you a current City of Henderson Employee?
If so, please type title, department:
I am available to begin on this date:
Once a week
Twice a week
and can provide services as follows (days/hours):
Areas of Interest
Click all that apply.
Education and Skills
Agreement, Consents and Releases, and Conditions
Please Initial to indicate you understand this statement
2. Informed Consent and Release:
I, , offer to volunteer my services to the City of Henderson. I realize that I will not be compensated in any way (including cash, privileges, benefits or future employment). I understand that the Department and/or I can cancel this agreement at any time. I release the City of Henderson, its employees, agents, leaders, instructors, contractors, and volunteers from any liability for loss or injury to my person or property which might occur due to negligence or other acts or omissions. This release applies to any losses or injuries which may occur as a result of, or during my participation in, volunteer service. I realize that this release is a binding contract. I have read and understand this release. I knowingly and voluntarily sign below. The City may use my photograph for any official Department publications and/or productions.
Please Initial to indicate you understand this consent
I fully understand, acknowledge and agree to the following conditions: The City of Henderson reserves the right to make the final decision on placement of volunteers. Background checks, review of current dated and provided motor vehicle records (if applicable) in accordance with City policy, will be conducted on applicants. Additionally, drug and alcohol screening tests may be conducted depending on the assigned responsibilities I am given as a volunteer. All statements made in this form are true and authorization is given to investigate all matters contained in this form. I authorize the City of Henderson to receive any criminal history information that may be contained in the files of any national, state, or local criminal justice agency. Any false statements or misrepresentations on this form will be cause for refusal of placement or immediate cessation of my services at any time during the period of my placement. I understand that the volunteer program does not qualify me for paid employment with the City of Henderson, and as a volunteer, I will not be entitled to any employee benefits, with the possible exception of workers compensation benefits, if applicable, and only to the extent provided by law.
Please Initial to indicate you understand these conditions
Volunteer Authorization Signature / Date:
Signature/Date of Parent/Guardian, if volunteer is a minor:
Once a volunteer vacancy is available in the area of interest you
have requested you will be contacted for a background to be completed.
Thank you for your interest in volunteer services with the City of Henderson.
IF YOU ARE UNABLE TO SUBMIT THIS FORM, PLEASE VISIT THE CITY OF HENDERSON HUMAN RESOURCES AT 240 WATER STREET TO OBTAIN AN APPLICATION.