Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Emergency Contact
*
Please provide a contact in case of emergency.
First Name
Last Name
Phone
*
(###)
###
####
Relationship
*
Demographic Information
*
Please provide the following information. It is only used to help us get a better idea of the demographic make-up of our volunteers.
MM
DD
YYYY
Gender
*
Education
*
Primary Education
Secondary Education or High School
Bachelor's Degree
Master's Degree
Doctorate or Higher
School
Volunteer Experience
*
Please list any organizations for which you have volunteered, your responsibilities and the dates that you volunteered there.
Work Experience
*
Please list any employers you have had in the last five years, dates of employment, and your responsibilities.
Volunteer Opportunities
*
Below is a partial list of volunteer opportunities available at the Chehalem Cultural Center. Please let us know which ones you are interested in:
Gallery Assistant, Education Assistant, Ceramics Studio Assistant, Special Event Assistant, Special Event Work Party, Wine Pourer
Special Skills
*
Please list any special skills you may have.
Accessibility Information
*
If you have any physical, medical, or psychological limitations or disabilities please list here along with any accommodations you need.
Have you ever been convicted of a crime?
*
If yes, was it a felony or misdemeanor? What was the nature of the crime?
CCC Waiver and Agreement
*
I certify that the information I have completed is true and give permission for this information to be
verified. I also understand that any false information will nullify my volunteer service with Chehalem
Cultural Center. CCC requires consent to a background check. You will be sent a form to fill out for the
background check once we receive your application.
I would like to participate in the volunteer program at Chehalem Cultural Center. I am doing so entirely
upon my own initiative, risk and responsibility. In consideration of the permission extended to me by
Chehalem Cultural Center through its officers and agents, I hereby, for myself, my heirs, my executors
and administrators, remise, release and discharge Chehalem Cultural Center, its officers and
employees from all claims, demands, actions, or causes of action, on account of any injury to me which may occur during any activity as a volunteer for Chehalem Cultural Center.
As a volunteer for the Chehalem Cultural Center, I am advised that Chehalem Cultural Center does not
carry Worker’s Compensation Insurance for participants or volunteers. If I suffer an injury while
volunteering, I am personally responsible for my medical or injury related expenses. I give permission
to the Staff in charge to secure emergency medical treatment for me in the event of an injury or
accident. Furthermore, I also agree to hold Chehalem Cultural Center, and/or its assignees, board of
directors, staff or volunteers harmless in the event of an injury or accident.
I have read and fully understand the terms and conditions of this volunteer agreement and I willingly
comply with all of its conditions.
If I am the parent or legal guardian of a child of a child under eighteen years old who is applying
through this on-line application, to volunteer for Chehalem Cultural Center, I hereby give consent for my
child or ward, as the case may be, to become a volunteer for Chehalem Cultural Center as described in
the above volunteer agreement and by checking below join in and agree to be bound by the terms and
conditions of the release above.
