Police Volunteer App by liuqingyan

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									                                                                                   FOR INTERNAL USE ONLY:



GRANITE FALLS POLICE DEPARTMENT
205 S Granite Ave
Granite Falls, WA 98252
360.691.6611



The Granite Falls Police Department is in the process of establishing a Police Volunteer
program that provides opportunities for the civilians to collaborate with the police department in
providing services to the citizens of Granite Falls. 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 the volunteer within our community and to capitalize on these abilities to augment
Police Services. The intent is also to provide a program that involves residents interested in
local law enforcement the opportunity to perform work of value to the community.
This application is designed to give applicants an opportunity to share their background,
experience, interests, and skills, enabling the Granite falls police Department to make the best
possible choice for a Police Volunteer. The Granite Falls Police does not discriminate based on
age, race, gender, religion, national origin, marital status, disability, or any other basis prohibited
by federal, state, or local law.

NAME: ___________________________________

ADDRESS: ________________________ CITY: _____________ STATE: ____ ZIP: _______

DATE OF BIRTH: _______________

TELEPHONE: (         ) ________________________

IN CASE OF EMERGENCY, PLEASE CONTACT: ____________________________________

PHONE: (       ) ________________________ RELATIONSHIP: _________________________

HAVE YOU BEEN CONVICTED OF A FELONY OR MISDEMEANOR CRIME OTHER THAN
MINOR TRAFFIC OFFENSES? YES       NO
IF YES, PLEASE EXPLAIN:
__________________________________________________________


DO YOU HAVE ANY MEDICAL CONDITIONS THAT SHOULD BE TAKEN INTO
CONSIDERATION IN ARRANGING VOLUNTEER ASSIGNMENTS?     YES                                  NO
IF YES, PLEASE EXPLAIN:
__________________________________________________________________


CIRCLE THE DAYS YOU CAN BE AVAILABLE FOR VOLUNTEER WORK:

       MONDAY            TUESDAY           WEDNESDAY             THURSDAY            FRIDAY
WHAT GENERAL SKILLS/EXPERIENCE/EDUCATION WOULD YOU LIKE TO SHARE IN YOUR
VOLUNTEER WORK?




     * SEE SUPPLEMENTAL QUESTIONNAIRE



IN WHAT PARTICULAR AREAS OF VOLUNTEER WORK ARE YOU INTERESTED?




REFERENCES (Do not list relatives)


NAME:                                   ADDRESS:              PHONE:

NAME:                                   ADDRESS:              PHONE:

NAME:                                   ADDRESS:              PHONE:

NAME:                                   ADDRESS:              PHONE:
I _____________________________ hereby volunteer my services to perform only the services
outlined in the attached scope of volunteer work for the City of Granite Falls Police Department.
I understand I will not be compensated for my work but I volunteer to do so in a responsible
manner. If I decide to discontinue my volunteer service, I will notify the Granite Falls Police
Department. Further, I hereby certify that I am capable of performing the duties as outlined in
the attached scope of volunteer work (check which applies) ( ) without accommodation or
 ( ) with the following accommodations:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

   1. _____ I understand that I am not to appear for volunteer services under the influence of
      any drugs or alcohol.
   2. _____ I will abide by all of the Granite Falls Police Department policies regarding
      personal conduct while performing volunteer services.
   3. _____ I agree not to go beyond the scope of volunteer work agreed without
      authorization.
   4. _____ Should an injury occur during the scope of my service, I understand that:
      _____ The City of Granite Falls has included my hours of volunteer service in the
      Washington State Department of Labor and Industries coverage for workers (once a
      timesheet is submitted to the City of Granite Falls).
      _____ I understand that I am to report any on-the-job injury or illness, no matter how
      minor, to the Granite Falls Police Department employee supervising my volunteer
      services.
   5. Depending on the scope of volunteer work, the following policies may apply:
              ____ Internet & Other Workplace Communication Systems
              ____ Alcohol, Drugs & Intoxicants
              ____ Workplace Harassment
   6. _____ I consent to a representative of the Granite Falls Police Department performing a
      background check into my history in accordance with RCW 43.43.830-839 and waive
      any right of privacy I may have in such information for the limited purpose of the Granite
      Falls Police Department considering it for determining my suitability as a volunteer.
   7. _____ I understand that I or the Granite Falls Police Department may terminate this
      agreement at any time without cause, that I am volunteering my services at will and may
      be asked to discontinue such without prior notice or reason.
   8. _____ I give permission for photos/videos taken of myself during volunteer activities to
      be used for publicity purposes, with recompense.

This agreement will be in effect for the duration of my volunteer services beginning this date.

Dated this _________ day of_____________________________ , 20 ____ .


                                                     ___________________________________
                                                                       Volunteer’s Signature


                                                     ___________________________________
                                                                      Parent/Legal Guardian
                                         NOTICE TO VOLUNTEERS

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


                                         SIGNATURE IS REQUIRED

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 police volunteer. Further, I give permission
for n authorized representative of the Department to conduct a criminal background check to include
(but not limited to): Criminal History Check (NCIC/WASIS), Driver’s License check (DOL), local police
database check (RMS), and any personal reference checks to inquire of individuals/institutions that
provide information from any liability that may arise from the provision of this information.

As a volunteer of the Granite Falls Police Department, I am fully aware that the work associated with
being a Police Volunteer involves certain risks. Being fully informed as to these risks and in
consideration of my being allowed to participate in the Police Volunteers 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, assignees, release and hold harmless the City
of Granite Falls, its officials, employees, and agents and waive any right of recovery that I might have
to bring claim or a lawsuit against them for personal injury, death or other consequences occurring to
me arising out of my volunteer activities.

I give my permission to have my photo taken and used for clerical and publicity purposes by the Police
Department. 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.

The above declaration is true and correct and made subject to penalty of perjury under the laws of the
State of Washington. Signed at _____________________________________________ , Washington,
this _____________ day of __________________________________ , 20 ______.



SIGNATURE: _____________________________________________________________

PARENT/GUARDIAN: ______________________________________________________

DATE: ___________________________
                         VOLUNTEER CONFIDENTIALITY
Granite Falls Police Volunteers have access to the Police Department and will sometimes hear
or see information that is confidential in nature. Police Volunteers are expected to maintain
that confidentiality. Any violation of this confidentiality is a violation of department policy and
state law and could result in jeopardizing an on-going investigation.



                            OATH OF CONFIDENTIALITY
   1. The undersigned agrees not to divulge, publish, or otherwise make known to anyone
      except criminal justice employees, orally or in writing, any information gained through
      access to the Granite Falls police Department.

   2. It is understood and agreed upon that the foregoing conditions DO NOT cease when
      the undersigned is no longer a volunteer with the Granite Falls Police Department. The
      undersigned is permanently bound by said regulations on confidentiality.

   3. Violations of conditions may subject the undersigned to disciplinary action, which may
      include termination of volunteer status, civil action, and/or criminal prosecution.




Signature of Volunteer                                                       Date



Printed Name of Volunteer
                       POLICE VOLUNTEER
                       “Supplemental Questionnaire”

1. Why do you want to be a volunteer for the Granite Falls Police Department?
   _____




2. Do you have any experience in volunteering? (If so, describe.)
   _




3. What type of time commitment do you have for the Police Volunteer position?
   _




4. As a Police Volunteer, do you feel that you can effectively honor privacy laws that
   involve the type of environment you will be in?
   _

								
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