VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES INDIVIDUAL NAME OF AGENCY AGREEMENT # NAME OF VOLUNTEER (First, Last) U.S. CITIZEN OR PERMANENT RESIDENT Yes No, list visa type_____________________________ NAME OF NAME OF GROUP CONTACT (First, Last) 7. 8. STREET ADDRESS CITY, STATE, ZIP CODE 9. EMAIL ADDRESS PHONE AGE Home: Under 15 15 - 18 19 - 25 Mobile: 26 - 35 36 - 54 55 and Older ETHNICITY & RACE (Optional): Please report both ethnicity and race and tell us if you are a veteran or have a disability. Multiracial respondents may select two or more races. This information will inform our understanding of diversity and inclusion among the volunteer force in the natural and cultural resource areas. Ethnicity (Select one): Race (Select one or more, regardless of ethnicity): Are you a Veteran? Yes No 14a. 14b. 14c. Hispanic or Latino American Indian or Alaskan Native Asian Not Hispanic or Latino Black or African American White Do you have disability? Yes No 14d. Native Hawaiian or Other Pacific Islander EMERGENCY CONTACT INFORMATION NAME (Last, First) PHONE EMAIL ADDRESS Home: Mobile: STREET ADDRESS CITY, STATE, ZIP CODE GOVERNMENT OFFICIAL COMPLETES THIS SECTION AGENCY CONTACT NAME (Last, First) AGENCY CONTACT & PHONE REIMBURSEMENTS APPROVED: Yes No VOLUNTEER POSITION/GROUP PROJECT TITLE: Type and Rate of Reimbursement: Description of service to be performed. Provide a brief abstract of volunteer or service activity and the location of the volunteer activity, and attach 24. description of service to be performed. Service description should include details such as time and schedule commitment, use of government vehicle, use of personal equipment and/or vehicle, skills required (note certifications if necessary), level of physical activity required, etc. If this is a group agreement, the leader is to provide the group name and attach a complete list of group participants or optional form 301b for each volunteer. VOLUNTEER/SERVICE ACTIVITY ABSTRACT Check all that apply: Description of service attached List of group participants/optional form 301b attached 25. Job Hazard Analysis Valid Driver’s License Verified (if required) PARENTAL CONSENT FOR VOLUNTEER AGE 18
VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES INDIVIDUAL NAME OF AGENCY AGREEMENT # NAME OF VOLUNTEER (First, Last) U.S. CITIZEN OR PERMANENT RESIDENT Yes No, list visa type_____________________________ 7. NAME OF 8. NAME OF GROUP CONTACT (First, Last) 9. STREET ADDRESS CITY, STATE, ZIP CODE EMAIL ADDRESS PHONE Home: Mobile: AGE Under 15 15 - 18 19 - 25 26 - 35 36 - 54 55 and Older ETHNICITY & RACE (Optional): Please report both ethnicity and race and tell us if you are a veteran or have a disability. Multiracial respondents may select two or more races. This information will inform our understanding of diversity and inclusion among the volunteer force in the natural and cultural resource areas. 14a. Ethnicity (Select one): Hispanic or Latino Not Hispanic or Latino 14b. Race (Select one or more, regardless of ethnicity): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander 14c. Are you a Veteran? Yes No 14d. Do you have disability? Yes No EMERGENCY CONTACT INFORMATION NAME (Last, First) PHONE Home: Mobile: EMAIL ADDRESS STREET ADDRESS CITY, STATE, ZIP CODE GOVERNMENT OFFICIAL COMPLETES THIS SECTION AGENCY CONTACT NAME (Last, First) AGENCY CONTACT & PHONE REIMBURSEMENTS APPROVED: Yes No Type and Rate of Reimbursement: VOLUNTEER POSITION/GROUP PROJECT TITLE: 24. Description of service to be performed. Provide a brief abstract of volunteer or service activity and the location of the volunteer activity, and attach description of service to be performed. Service description should include details such as time and schedule commitment, use of government vehicle, use of personal equipment and/or vehicle, skills required (note certifications if necessary), level of physical activity required, etc. If this is a group agreement, the leader is to provide the group name and attach a complete list of group participants or optional form 301b for each volunteer. VOLUNTEER/SERVICE ACTIVITY ABSTRACT 25. Check all that apply: Description of service attached List of group participants/optional form 301b attached Job Hazard Analysis Valid Driver’s License Verified (if required) PARENTAL CONSENT FOR VOLUNTEER AGE 18
OF301aVolunteerAgreement-2014%20(1)%20(1).docx