Form Center

2. 
4. Volunteer position applied for must be specified.
6. Volunteer Area of Interest *

   1. Adult Wellness Center
   2. Library
   3. Animal Shelter
   4. Parks and Recreation
   5. Museum
   6. Recycling Center
7. Date of application *
   Date of application
9. Time commitment desired*

   1. One Time / Scheduled
   2. On Going / Scheduled

   1. Group Event
11. Last Name*
12. First Name*
13. Middle
15. Address1*
17. City
18. State
19. Zip
21. Phone Number*
22. Alternative Phone Number
23. Email Address
25. When is the best time to contact you?
27. Date available volunteer*
    Date available volunteer Start Date

    —

    Date available volunteer End Date
28. If you are under 18 can you also provide the required adult supervision; other than city staff.*

    1. Yes

    1. No
30. Have you ever been convicted of a crime?*

    1. Yes

    1. No
32. If so, please provide dates and details
    Answering “yes” to these questions does not constitute an automatic bar to volunteering. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
36. Any Special Interest or Talents?
38. Any additional information you would like us to know?
40. List names and relationship of any relatives currently employed by the City of Rogers.
42. Waiver of Liability
    I hereby request permission of the City of Rogers and its’ agencies (hereafter collectively referred to as “City”), to volunteer to work at and participate in the activities of the City. In consideration for such permission, I agree to follow all instructions given by any City employee; I accept full responsibility for my own personal safety; I waive any and all rights or claims against the City in the event of any accident, incident or injury; and I do hereby release any and all employees of the City, and all individual members of the City staff from any and all liability for any injury that I could or do sustain while participating in City activities or service. I understand that working with City employees while performing City functions can be unpredictable and dangerous, and I hereby assume the risks associated with undertaking those activities. In the event of an accident or injury, I authorize the City to notify _______________________at the following phone number ______________________________________. (Fill in Emergency Contact at bottom of form)
44. I have read the above waiver and agree to follow the instructions I am given. I understand that, in the event that I am injured, I am forfeiting any claim, including fees, costs, expenses, compensation, or any sums from any City source whatsoever, against the City or its employees or agents. I further understand that the City of Rogers and its’ agencies are immune from liability and from suit for certain damages except to the extent that they may be covered by liability insurance and that no tort action shall lie against any such political subdivision because of the acts of its’ agents and employees. (See A.C.A. 21-9-301 for specific information) I further understand that this Waiver shall remain valid indefinitely or until revoked by me, in writing, with at least 7 days prior notice given to the City of Rogers.
46. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
    I certify that I have read, fully understand and accept all terms of the Waiver of Liability.
48. Applicant Signature*
49. Date*
    Date
51. Emergency Contact: Name
53. Emergency Contact: Phone Number
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field