Volunteer Registration Packet

Communities to Volunteer:

First Name

Last Name

Street Address

Apt #

City

State

Zip

Enter Email Address

Confirm Email Address

Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Can you commit to a specific length of service?

Yes

No

Days and hours available:

Do you have a valid drivers license?

Yes

No

Drivers License # (Type "N/A" if not applicable):

Do you have current vehicle insurance as required by Michigan law?

Yes

No

Have you ever been convicted of a criminal violation (misdemeanor or felony) of the law other than minor traffic violations?

Yes

No

If "Yes" please explain (Type "N/A" if not applicable):

Are there pending criminal charges against you?

Yes

No

Are you volunteering to satisfy court ordered community service?

Yes

No

Have you ever been dismissed or requested to resign from a volunteer position?

Yes

No

If "Yes" please explain (Type "N/A" if not applicable):

I attest the information provided.

I agree.

I do not agree.

Electronic Signature:

Date:

I understand that the Wayne County Department of Senior Services, as a condition of employment, volunteer and/or contract work is required to run a complete check of any possible criminal record(s) that I might have. I understand that any information found regarding convictions or felony charges might result in my being refused employment, volunteer and/or contract work with the County of Wayne.

I authorize Wayne County to perform necessary background check to volunteer.

I do not authorize Wayne County to perform necessary background check to volunteer.

Date of Birth:

Gender:

Race:

Wayne County Service Assistant

Senior Services

Senior Services

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