Volunteer Services
Agreement for Natural Resources Agencies for Individuals or Groups |
|||||
Please print when completing this form |
|||||
Site Name/Project
Leader |
Agency |
Reimbursement (if any) |
|||
Name of Volunteer or Group Leader – Last, First, Middle |
Under
18 18-25 26-55 56 and
Older |
||||
Yes No Visa
Type |
Email Address |
Home Phone |
Mobile Phone |
||
Street Address |
City |
State |
Zip |
||
IF VOLUNTEER IS UNDER AGE 18 – Name of Parent or Legal Guardian |
Home Phone |
Mobile Phone |
Email Address |
|||||||||
Street Address |
City |
State |
Zip |
|||||||||
I affirm that I am the
parent/guardian of the above named volunteer. I understand that the agency
volunteer program does not provide compensation, except as otherwise provided
by law; and that the service will not confer on the volunteer the status of a
Federal employee. I have read the attached description of the service that
the volunteer will perform. I give my permission for |
||||||||||||
|
to participate in the
specified volunteer activity sponsored |
|||||||||||
by |
at |
|
|
|||||||||
|
(Name of Sponsoring Organization, if applicable) |
|
(Name of Volunteer Duty Station) |
|
||||||||
From |
|
to |
|
|
|
|
|
|
||||
|
(Date) |
|
(Date) |
|
(Parent/Guardian Signature) |
|
(Date) |
|
||||
Emergency Contact Name |
Home Phone |
Mobile Phone |
Email Address |
Street Address |
City |
State |
Zip |
GOVERNMENT
OFFICIAL COMPLETES THIS SECTION |
|||||||||||||||
Description of service to be performed. Include details such as time and
schedule commitment, use of personal equipment, government vehicle, skills
required (note certifications if necessary), level of physical activity
required, etc. Attach the complete job description and job hazard analysis to
this form. If this is a group agreement, the leader is to provide the group
name, a complete list of group participants to be attached to this form, and
parental approval (above) completed for each volunteer under the age of 18. |
|||||||||||||||
Government Vehicle required? |
|||||||||||||||
Personal Vehicle to be used? |
Yes |
No |
Please verify that the volunteer is in possession of one of these
documents. DO NOT keep a copy of the document for his/her file. |
||||||||||||
I understand that I will not receive any compensation for the above
service and that volunteers are NOT considered Federal employees for any
purpose other than tort claims and injury compensation. I understand that
volunteer service is not creditable for leave accrual or any other employee
benefits. I also understand that either the government or I may cancel this
agreement at any time by notifying the other party. I understand
that my volunteer position may require a reference check, background
investigation, and/or a criminal history inquiry in order for me to perform
my duties. I understand
that all publications, films, slides, videos, artistic or similar endeavors,
resulting from my volunteer services as specifically stated in the attached
job description, will become the property of the United States, and as such,
will be in the public domain and not subject to copyright laws. I understand the
health and physical condition requirements for doing the work as described in
the job description and at the project location, and certify that the
statement I have checked below is true: I know of
no medical condition or physical limitation that may adversely affect my
ability to provide this service. I do know
of a medical condition or physical limitation that may adversely affect my
ability to provide this service and have explained
I do hereby
volunteer my services as described above, to assist in agency-authorized
work. I agree to follow all applicable safety guidelines. |
|
||||||||||||||
|
|
|
|
|
|||||||||||
|
(Signature of Volunteer) |
|
(Date) |
|
|
||||||||||
The above-named agency agrees, while this arrangement is in effect, to
provide such materials, equipment, and facilities that are available and
needed to perform the service described above, and to consider you as a
Federal employee only for the purposes of tort claims and injury compensation
to the extent not covered by your volunteer group, if any. |
|
||||||||||||||
|
|
|
|
|
|||||||||||
|
(Signature of Government
Representative) |
|
(Date) |
|
|
||||||||||
Termination of Agreement |
|||||||||
Volunteer requests
formal evaluation |
|
Evaluation Completed |
|
|
|
||||
|
|
|
|
|
|
(Date) |
|
||
Agreement terminated on |
|
|
|
||||||
|
(Date) |
|
(Signature of Government Representative) |
|
|||||
Public Burden Statement According to the Paperwork Reduction Act of 1995, an agency
may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0596-0080. The
time required to complete this information collection is estimated to average
15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) and U.S. Department
of the Interior (USDI) prohibit discrimination in all programs and activities
on the basis of race, color, national origin, gender, religion, age,
disability, political beliefs, sexual orientation, and marital or family
status. (Not all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA’s
TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272
(voice) or (202) 720-6382 (TDD). USDA and USDI are equal opportunity
providers and employers. |
Privacy Act Statement Collection and use is
covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is
consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which
authorizes acceptance of the information requested on this form. The data
will be used to maintain official records of volunteers of the USDA and USDI
for the purposes of tort claims and injury compensation. Furnishing this data
is voluntary, however if this form is incomplete, enrollment in the program
cannot proceed. |