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~ ~W <br />NICE WORKER <br />i_n„~-~=`~'' To be used in conjunction with a <br />'-: ,, -' - <br />c E N T E ~ Disaster Volunteer Intake and Referral Form <br />] City of Campbek <br />3 City of Cuper5no <br />7 City of Gilroy <br />3 CRy of ios At:os <br />O town o. Los A:los Hi4=_ <br />D Town o` Los Gates <br />3 City of Milpitas <br />'] City of Monte Sereno <br />O City of Morgan Hill <br />City of M{n. View <br />O City of Paio Alto <br />City of San Joss <br />3 City of Sarfa Clara <br />] CRy o4 Saratoga <br />D CRy of Sunnyvale <br />] Count' of Santa Clara <br />D Offer <br />PRINT PL=.45E <br />Name: <br />First Ilil.l. <br />Last Date: I City 1 Jurisdiction: <br />_. <br />Street Address: ;City, State, Zip Code: <br />i Driver's License Class and # OR ID #: <br />Primary Phone: CeU /Pager: Email: <br />Hair Color: Eye Color: Height: Are you able to lift heavy items? YES NO i <br />tf es, u to how man ounds? <br />J DSW Classification: <br />l HAM Radio License !Call Sign: <br />I <br />In case of emergency, contact: <br />Name ~ <br />;Emergency Contact Phone: <br />Do you have any existing physical or mental limitations that would affect your ability to volunteer and where you are assigned? N_ Y_ <br />If yes, please describe accommodations needed: <br />Have you ever been convicted of a felony or misdemeanor? NO YES <br />If yes, list all convictions after your t 8`" birthday, including date and nameAocation of court where convicted. (A "yes" answer is not an <br />automatic bar to placement; a false statement will disqualify you. If yes, please explain fully. Attach a separate sheet of paper if <br />necessary.) <br />Volunteer Disaster Service Agreement <br />As a City/County of Disaster Service Volunteer, I agree to perform my assignment to the best of my <br />ability, to accept supervision for the duration of the assignment, and to observe all safety guidelines and other rules and policies of the <br />City/County of I agree to the physical demands required for duty assigned. I understand and <br />acknowledge that I am not an employee of the City/County of and as such, am not eligible for <br />compensation from the CitylCounty arising from the services I am voluntarily providing. <br />I hereby certify that the statements on this form are true and correct Depending on the nature of volunteer activities, fingerprinting <br />and/or a background check may be required. <br />Volunteer Signature Date <br />TO BE COMPLETED IN THE PRESENCE OF DISASTER SERVICE WORKER OFFICIAL <br />Disaster Service Worker Loyalty Oath or Affirmation (Govt. Code §3102) <br />I, , do solemnly swear that I will support and defend the Constitution of <br />the United States and the Constitution of the State of Califomia against all enemies, foreign and domestic; that I will bear true faith and <br />allegiance to the Constitution of the United States and the Constitution of the Slate of Califomia; that I take [his obligation freely, without <br />any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties which I am about to enter. I certify <br />under penalty of perjury that the foregoing is True and correct. <br />DATE SIGNATURE OF DISASTER VOLUNTEER IF UNDER 18 YEARS OLD, SIGNATURE OF PARENT/GUARDIAN <br />SIGNATURE OF OFFICIAL AUTHORIZED TO ADMINISTER LOYALTY OATH TITLE <br />'Far a volunteer registering for an intermittent or a single event, the expiration date is set at the discretion of the accredited Disaster Council Gut not to <br />exceed one year. (Go•rt. Code §3102) <br />position Assigned: DS4V Class cation: Lceation: <br />Supervisor Assigned: Phone >g et' EVC Staff Person: <br />Comments' <br />Office of Emergency Services Pink copy - Voturlteer <br />S?e Pane 2 <br />