2. Volunteer Program

   The Port Angeles Police Department operates a volunteer program that provides services organization-wide. The purpose of the program is to enable the Police Department to take advantage of the extraordinary reserve of knowledge, talent, and skill possessed by volunteers within our community and to capitalize on these abilities to augment Police Department services. The intent is also to provide a program which involves interested residents in local government while providing them the opportunity to perform work of value to the community.

    

   The volunteer application is designed to give applicants an opportunity to share their background, experience, interests and skills, enabling the Police Department to make the best possible volunteer placement. Please be sure to answer all of the questions below.

4. Last Name*
5. First Name*
6. Middle Name*
8. Date of Birth*
9. Address*
11. Home Phone*
12. Message Phone
13. Work Phone
14. Email
16. Do you have a valid Washington State Driver's License?*

    1. Yes
    2. No
17. Can you obtain a valid Washington State Driver's License?

    1. Yes
    2. No
18. WA State Driver's Lic#
19. Expiration Date
21. WA State ID Card #
22. Expiration Date
24. Availability*

    1. Long-Term
    2. Short-Term
    3. Special Project
25. Days You Can Be Available for Volunteer Work (Select all that apply)*

    1. Sundays
    2. Mondays
    3. Tuesdays
    4. Wednesdays
    5. Thursdays
    6. Fridays
    7. Saturdays
26. Are you certified in any of the following? (Select all that apply)*

    1. CPR
    2. First Aid
    3. None of the Above
28. In What Particular Areas of Volunteer Work Are You Interested?*
30. What General Skills/Experience/Education Would You Like to Share in Your Volunteer Work?*
32. Criminal Convictions
34. Have you been convicted of a felony or released from prison within the last ten (10) years?*

    1. Yes
    2. No
35. Have you been convicted of a misdemeanor other than minor traffic offenses within the past three (3) years?*

    1. Yes
    2. No
37. Please Explain
39. References (Do Not List Relatives)
41. Name*
42. Address*
43. Phone*
45. Name*
46. Address*
47. Phone*
49. Name*
50. Address*
51. Phone*
53. Do you have any medical conditions, physical or emotional, that should be taken into consideration in arranging volunteer assignments?*

    1. Yes
    2. No
55. Please Explain
57. Emergency Contact
59. Name*
60. Address*
61. Phone*

63. Notice to Volunteers

    Volunteers are not considered to be City of Port Angeles employees. Injury Compensation is provided through the Department of Labor & Industries. Volunteer service is considered to be creditable work experience. The data furnished on this form is furnished voluntarily and will be used to contact, interview and place volunteers.

65. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

67. Electronic Signature*

    1. I agree

69. To the best of my knowledge, the information herein is true and complete. I understand that falsification of this application is grounds for dismissal as a volunteer. Further I give permission for an authorized representative of the City to conduct a state patrol criminal background check in accordance with RCW 43.43.830-839 and to inquire of individuals about my ability to perform all aspects of the volunteer position for which I am being considered and I release the City of Port Angeles and those individuals/institutions that provide information from any liability that may arise from the provision of this information.

    As a volunteer for the City of Port Angeles, I am fully aware that the work associated with being a City Volunteer involves certain risks of physical injury or death. Being fully informed as to these risks and in consideration of my being allowed to participate in the City's Volunteer Program, I hereby assume all risk of injury, damage and harm to myself arising from such activities or use of City facilities. I also hereby individually and on behalf of my heirs, executors and assignees, release and hold harmless the City of Port Angeles, its officials, employees and agents and waive any right of recovery that I might have to bring a claim or a lawsuit against them for any personal injury, death or other consequences occurring to me arising out of my volunteer activities.

    I give permission to have my photo taken and used for publicity purposes by the City. I authorize any necessary emergency medical treatment that might be required for me in the event of physical injury and/or accident to me while participating in this program.

71. Signature*

    First M. Last

72. If Under 18 Parent or Guardian's Signature

    First M. Last

74. Notification and Authorization for Background Investigation Disclosure Statement

    In compliance with RCW 43.43.830-845, all applicants who have been offered a position as a volunteer, and in which position the person may have unsupervised access to children under sixteen years of age, to developmentally disabled persons, or to vulnerable adults, are required to disclose the following information:

76. Have you ever been convicted of any crime against children or other persons*?*

    1. Yes
    2. No

    *Crime against children or other persons means a conviction of any of the following offenses: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree assault of a child; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; endangerment with a controlled substance; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of these crimes as they may be renamed in the future.

78. Have you been convicted of crimes relating to financial exploitation where the victim was a vulnerable adult?*

    1. Yes
    2. No
80. Have you been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor?*

    1. Yes
    2. No
82. Have you been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?*

    1. Yes
    2. No
84. Have you been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person, or to have abused or financially exploited a vulnerable adult?*

    1. Yes
    2. No
86. Have you been found by a court in a protection proceeding under Chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult?*

    1. Yes
    2. No
88. For each question that you answered Yes, please describe the location, date and facts of the conviction and make reference to the question being answered

90. The City of Port Angeles shall make an inquiry to the Washington State Patrol regarding an applicant's conviction record, disciplinary board final decision, or civil adjudication record. Applicants will be notified of the State Patrol's response within ten working days of receipt of this information by the City of Port Angeles. A copy of the response will be made available to the applicant.

    I acknowledge that I have read the entire Notification and Authorization for Background Investigation Disclosure Statement, that I understand the requirements, and I grant permission to the City of Port Angeles to make an inquiry to the Washington State Patrol under the provisions of this law, pursuant to RCW 9A.72.085. I certify that under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

92. Applicant's Signature*

    First M. Last

93. Social Security Number*
95. Applicant's Date of Birth*
96. Applicant's Place of Birth*
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit

* indicates a required field