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Volunteer Application

2. First Name*

3. Last Name*

5. Address:*

7. City:*

8. State:*

9. Zip Code:*

11. Email:

12. Phone Number:*

14. Emergency Contact Name:*

15. Emergency Contact Phone Number:*

19. Motor Vehicle Operation
    If you anticipate operating a motor vehicle for and in behalf of Roosevelt City while acting as a volunteer for the City, please fill out the Driver's License information below.

    If you anticipate operating a motor vehicle for and in behalf of Roosevelt City while acting as a volunteer for the City, please fill out the Driver's License information below.

21. Driver's License Number:

22. State Issued:

23. Expires:

27. Volunteer Verifications*

    Have you ever been convicted of a misdemeanor (excluding moving violations) or a felony?

    1. YES
    2. NO
29. If you answered "YES" above, please explain.

    (Please note: a "YES" answer is not an automatic disqualification.)

33. Volunteer Agreement
    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 as long as you are preforming duties pre-determined in your scope of work. Your exclusive remedy for personal injury or occupational diseases will be workers' compensation medical benefits.

    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 as long as you are preforming duties pre-determined in your scope of work. Your exclusive remedy for personal injury or occupational diseases will be workers' compensation medical benefits.

35. By making this application, I hereby authorize Roosevelt City 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 Roosevelt City of any liability for the use of this information in considering and reviewing my application.

    By making this application, I hereby authorize Roosevelt City 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 Roosevelt City of any liability for the use of this information in considering and reviewing my application.

37. 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 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.

39. Sexual Harassment Policy Agreement*

    1. I have read and signed the sexual harassment policy.

41. Electronic Signature

Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field