Volunteer Application Apply to be a Volunteer Date* Name* First Last Current Age*If under 18, you will have to print this application and have your parents sign it.14-1718 or overAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone*Email* Placement and Goals for Your Volunteering ExperienceAre you volunteering for:*An Internship/PracticumCommunity Service for School RequirementTo Serve our CommunityI am interested in the following volunteer opportunity:*Please read service descriptions. Some have requirements you must meet in order to serve in those areas. (You may check more than one, however you may only be assigned to one.) Quest Mixers (6-8 p.m. 1st and 3rd Wednesdays) Quest Horticulture Marketing Intern Social Work Practicum/Internship Fiscal Intern Wittenberg Work Study How many hours per week would you like to serve?*If volunteering to fulfill a school requirement, on what date must your hours must be completed? Please list any experience you have had working with people who are developmentally disabled. (none is required to volunteer)*Do you know anyone employed by Developmental Disabilities of Clark County? If so, who?Emergency InformationIn the event of an emergency, please list who we should call and any information that should be passed on to first responders.Person We Should Contact in Case of Emergency* First Last Phone Number of Your Emergency Contact*Agreement and WaiverI understand that if I am under the age of 18, I must print this application and have my parent or guardian agree to and sign this waiver. I swear that all the information in this application is true. I understand and give permission for a variety of background checks. I understand that as a volunteer of Developmental Disabilities of Clark County, I am not included in insurance coverage. I hereby waive on behalf of myself and my executors, administrators and assigns, all claims for damage or loss to my person and property which my be caused by an act or failure to act of Developmental Disabilities of Clark County, its officers, agents or employees. I assume the risk for all hazardous conditions in and about the premises and waive any and all specific notice of the existence of such conditions. I give permission for photos of me to be used in publicity materials for Developmental Disabilities of Clark County. By typing my name below, this constitutes my legal signature and agreement to this waiver.*Date Signed* Signature of parent or guardian if under 18 If under 18, parent/guardian phoneNameThis field is for validation purposes and should be left unchanged.