Name: _____________________________

Master 4-H Volunteer Application We invite you to register for our Master 4-H Training on Sunday, February 12th at Chinquapin Park Recreation Center & Aquatics Facility (3210 King St.) in Alexandria. We are looking for responsible, caring adults to support 4-H positive youth development in Arlington and Alexandria by leading educational activities. To register, please submit your completed application and apply for your background check. Submit Applications to: Alexandria Attn: Reggie Morris 1108 Jefferson Street Alexandria, VA 22314 [email protected]

2014

Arlington Attn: Caitlin Verdu 3308 S. Stafford St. Arlington, VA 22206 [email protected]

Virginia Polytechnic Institute and State University

3000-0000

Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Jewel E. Hairston, Administrator, 1890 Extension Program, Virginia State, Petersburg.

Why Participate? Volunteers will learn to lead fun educational activities, receive resources and support, and be matched with another volunteer. Together we’ll enjoy working with youth to develop their potential, and make a difference in your community. Program Details: On Sunday, February 12th Arlington and Alexandria 4-H are offering a Master 4-H Volunteer training from 10-4PM at Chinquapin Park Recreation Center & Aquatics Facility (3210 King St.). Training will cover 4-H basics, experiential learning, teaching life skills, risk management, and hands-on activities in two project areas: 4-H Cloverbuds, and 4-H National Youth Science Series. The purpose of the training is to find caring, responsible adult volunteers who are willing to help lead youth activities this February and March. Volunteers are encouraged to give back six hours by delivering six, one-hour programs to youth in the community. We will train you, find you a partner, introduce you to a group of interested kids, and support you through the program. Volunteers will choose one program to assist with. The options are: 1) 4-H Cloverbuds

This is 4-H programming for youth ages 5-8. The purpose is to create an environment for families to come together and participate in learning activities that engage the whole family. Teach the youngsters in your life about citizenship, nature studies, science, cooking, and much more. This is a great way to make new friends (for both kids and adults) and try new things. Program times are flexible.

2) 4-H National Youth Science Projects

This is programming for elementary aged youth in afterschool programs (through Extended Day in Arlington and OST in Alexandria). Volunteers lead pre-planned science activities for elementary-aged youth. Together you will explore the science behind drones, rockets, GIS, and more. This is a great fit for those passionate about science and discovery, but no technical background is required. Programs typically run from 4-5pm one day a week. If you are a person with a disability and desire assistance or accommodation, please notify Octavia Walker in the City of Alexandria at (703) 746-5546 during business hours of 8 a.m. and 5 p.m. TDD number is (800) 828-1120.

Expectations for Volunteers: Volunteers are asked to complete a minimum of six, one-hour activities through either the 4-H Cloverbuds or the 4-H National Youth Science Series. Programs will run February through March, one day a week. We will work with you to find an arrangement that fits your schedule. In addition, volunteers are expected to: Ensure the safety of youth in the program Complete a background check with Virginia Cooperative Extension Complete paperwork including volunteer application, group enrollment form, and program plan Give 4-H Office at least 24 hours of notice for a cancelled program Be flexible, have a back-up plan, and have fun Immediately report any issues or concerns to the 4-H Office (703-228-6404 – Arlington / 703746-5546 - Alexandria)

To register for the February 12th training and apply to be a 4-H Volunteer, please complete the following application. Return this packet by e-mail or in person to your local Extension Office.

Please answer the following questions: 1. Is there a specific group of kids (in a neighborhood, school, youth organization, etc.) that you would like to work with? (Yes) (No) If so, please provide their contact information: Group Name: ________________________Contact Person: ___________________________ Phone Number: ___________________________________________________________________ E-mail Address:____________________________________________________________________ 2. Do you have experience with 4-H, either in Arlington/Alexandria or in another locality? (Yes) (No) If so, where?

3. Do you prefer to work with a certain age group? (Yes) (No) If so, what age?

If you are a person with a disability and desire assistance or accommodation, please notify Octavia Walker in the City of Alexandria at (703) 746-5546 during business hours of 8 a.m. and 5 p.m. TDD number is (800) 828-1120.

4. Is there a specific adult volunteer you would like to work with? (Yes) (No) If so, who? 5. The program options are 4-H National Youth Science Series and 4-H Cloverbuds. Which of these interest you most? (You can always change your mind during training.)

Master 4-H Volunteer Application Checklist 1) Complete and return this application to your local Extension office. 2) Background Check: Send an e-mail to Kisha Simpson (Arlington) at [email protected] or Octavia Walker (Alexandria) at [email protected] and ask to complete your background check. The respondent will then reply with instructions and a link to complete the process. There is a $10 fee to complete the background check.

VCE – Alexandria Attn: Reggie Morris 1108 Jefferson Street Alexandria, VA 22314

VCE – Arlington Attn: Caitlin Verdu 3308 S. Stafford St. Arlington, VA 22206

Please plan to attend the training on Sunday, February 12th from 10-4pm at the Chinquapin Park Recreation Center & Aquatics Facility (3210 King St.). An Extension Agent will contact you before the training day to go over logistics and answer any questions you might have. If you have any questions, please reach out to your local agent. Caitlin Verdu: 703-228-6404 or [email protected] Reggie Morris: 703-746-5547 or [email protected]

If you are a person with a disability and desire assistance or accommodation, please notify Octavia Walker in the City of Alexandria at (703) 746-5546 during business hours of 8 a.m. and 5 p.m. TDD number is (800) 828-1120.

4-H Volunteer Application/Enrollment Long Form VA-114 Publication 388-003 Revised 2013

*

When applying for a volunteer role, complete sections A through I. After acceptance, read and sign section J. A. GENERAL INFORMATION (please print) Name: __________________________________________________________________________________ LAST

FIRST

MI

Mailing Address: ___________________________________________________________________________

STREET, BOX, ROUTE, APT #

CITY

STATE

ZIP

Residence: ______________________________________________________________________________

(Physical location if different than mailing address)

How long at this address: _________________________

Date of Birth: _______________________

B. CONTACT INFORMATION Phone: Daytime: (_______)_____________________

FAX: (_______)______________________

Evening: (_______)_____________________

E-mail: _______________________________

Best time to call: o Morning

o Afternoon

o Evening

Emergency Contact: Name _________________________________________________________________ Phone: Daytime: (_______)_____________________

Evening: (_______)_____________________

C. VOLUNTEER POSITION 1. Years as a 4-H Volunteer counting this year _____

2. 4-H Alumni: o Yes o No

3. I am a 4-H All-Star o Yes o No 4. I belong to 4-H Leader Association o Yes o No o Please send information 5. With which groups do you prefer to work? (check ALL that apply) Age: o Youth o under age 5 o Adults o age 5-8 o Either o age 9-11 Gender: o Males o age 12-13 o Females o age 14-18 o Either o over 18 7. Name of 4-H Club(s): ___________________________ 6. 4-H Volunteer Leader Types: Code ____________________________________________ o Organizational 41 ____________________________________________ o Project Leader 42 ____________________________________________ o Activity Leader 43 o Helper 44 8. Project(s) to which you give leadership: o Master Volunteer 45 ____________________________________________ o Collaborator 46 ____________________________________________ o Teen Leader 48 ____________________________________________ www.ext.vt.edu

*18 USC 707

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Polytechnic Institute and State University, 2014

Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, genetic information, marital, family, or veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Jewel E. Hairston, Administrator, 1890 Extension Program, Virginia State, Petersburg. VT/0114/4H-196

9. Describe your skills, abilities, and hobbies, as related to this volunteer position. ____________________________________________________________________________________ ___________________________________________________________________________________ 10. Describe your training, formal education, licenses/certification and experience working with different age groups or targeted clientele related to this position _____________________________________________________________________________________ _____________________________________________________________________________________ 11. Does the 4-H group with which you work have a website? Yes ____ No ____

If so, what is the website address?_________________________________________________________

D. AVAILABILITY 1. For what length of time are you willing to volunteer? 2. Over what time period? (mark all that apply) o hours per week(please specify) _______________ o 3 months o hours per month (please specify) _____________ o 6 months o negotiable (please specify) __________________ o 1 year o other (describe) _____________________ o When could you begin? _______________

(mo/day/yr)

3. When are you available to volunteer? o Day o Weekends o Specific Times _______________________________________________ o Evening o I’m flexible E. EMPLOYMENT/VOLUNTEER EXPERIENCE (supervisor may be contacted) Organization: _________________________ Supervisor Name and Phone #: ____________________________ o Paid or o Volunteer

Role/Duties: __________________________________________________________

_________________________________________________________ Organization: _____________________ o Paid or o Volunteer

Supervisor Name and Phone #: ___________________________

Role/Duties: _________________________________________________________

_________________________________________________________ F. REFERENCES 1. _____________________________________________________________________________________

(Name)

(Phone: Day & Night)

(Relationship)

______________________________________________________________________________________

(Street, Route, Box, Apt#)

(City)

(State)

(Zip)

2. _____________________________________________________________________________________

(Name)

(Phone: Day & Night)

(Relationship)

______________________________________________________________________________________

(Street, Route, Box, Apt#)

(City)

(State)

(Zip)

3. _____________________________________________________________________________________

(Name)

(Phone: Day & Night)

(Relationship)

______________________________________________________________________________________

(Street, Route, Box, Apt#)

(City)

(State)

(Zip)

G. DRIVING INFORMATION (Complete only if applying for a position which requires driving) Do you have a current and valid driver’s license? If yes, issued in the state of _____________ Do you have a current commercial driver’s license (CDL)? Do you currently have the minimum vehicle insurance coverage as required by the Commonwealth of Virginia?

Yes No o o o

o

o

o

H. BACKGROUND INFORMATION (This information will be kept in a confidential manner and accessible only to authorized personnel. A “yes” answer does not automatically exclude you from becoming a registered VCE volunteer.) 1. Have you ever had any criminal convictions related to: Yes No a. alcohol or drug abuse? o o b. child abuse or neglect? o o c. spousal abuse? o o d. elder abuse or neglect? o o 2. Have you ever been convicted of any violation(s) of law?

o

o

3. If volunteering for a position that o requires the operation of a vehicle, have you been convicted of any moving traffic violations within the last 5 years?

o

If “yes” to any of the above, please describe. ______________________________________________________________________________________ ______________________________________________________________________________________ I understand that records and criminal background or reference checks may be conducted on me at any time during the application process or during volunteer service of VCE. ____________________________________________________________

Signature, Volunteer Applicant

_______________________ Date (mo/day/yr)

I. DEMOGRAPHIC INFORMATION (For record keeping purposes only) 1. Gender: 2. Ethnicity: o Female o Hispanic o Male o Not Hispanic 3. Race: 4. I Live (check one) o White o On a farm o African American o Rural area or town under 10,000 o American Indian o Town or city of 10,000 to 50,000 o Asian o Suburb or city over 50,000 o City over 50,000 5. Highest level of education: ______________________________________________________________

J. ENROLLMENT/AGREEMENT • I agree to abide by all policies and procedures of Virginia Cooperative Extension (VCE). • I understand that Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, religion, sex, age, veteran status, national origin, disability, or political affiliation. VCE is an equal opportunity employer. • I hereby certify that all of the entries on this application are true and complete. I understand that any falsification of information herein constitutes cause for dismissal. ____________________________________________________________

_______________________

Signature, VCE Volunteer

Date (mo/day/yr)

FOR VCE INTERNAL USE ONLY A. ACTION TAKEN Date Volunteer Application received by VCE ___________________________ This applicant: (pick one) o was assigned to _______________________________ position on _____________

(Date)

o Met qualifications for position and was archived for future positions. o Not offered position. ____________________________________________________________

Signature, VCE Representative

_______________________ Date (mo/day/yr)

B. RE-ENROLLMENT o Re-enroll with no changes

Date _______________________

o Re-enroll with the following changes

Date _______________________

______________________________________________ __________________________________________

Signature, VCE Volunteer

Signature, VCE Supervisor

4-H Plus Data Codes UNIT:

ID NUMBER:

DATE: ____/____/____

CLUB:

TYPE:

COMMUNITY:

MAIL: Y=Yes N=No

4-H Adult Health History Report Form Publication 4H-224 2013-2014

INSTRUCTIONS: Please provide information concerning your health for participation in 4-H Events for the current year. If you are a person with a disability and desire any assistive devices, services, or other accommodations to participate in activity, please contact your local Extension office during business hours at least 7 days prior to the event to discuss accommodations. PLEASE PRINT ALL INFORMATION. (NOTE: Both sides of this form must be completed.) COUNTY ____________________________________________________________________

IDENTIFICATION NAME ______________________________________________________________________ FEMALE

Last

First

o

MALE

o

MI

MAILING ADDRESS _______________________________________ CELL PHONE (_______) ___________________ CITY __________________________________________________________ STATE______ ZIP__________________ HOME PHONE (______) ___________________ BIRTHDATE _______________ EMAIL________________________

EMERGENCY CONTACT NAME _______________________________________________________ CELL PHONE (_____) ________________ ADDRESS ____________________________________________________ HOME PHONE (_____) ________________ RELATIONSHIP___________________________________ WORK PHONE (_____) ________________

PHYSICIAN/INSURANCE INFORMATION NAME OF PHYSICIAN _______________________________________________ PHONE (_____) ________________ MEDICAL/HOSPITAL INSURANCE ____________________________________________________________________

Carrier

Policy ID #

MEDIA RELEASE The Virginia Polytechnic Institute and State University/College of Agriculture and Life Sciences (CALS) periodically uses electronic and traditional media (e.g., photographs, video, audio footage, testimonials) for publicity and educational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to the College of Agriculture and Life Sciences and its designee to use such reproductions for educational and publicity purposes in perpetuity without further consideration from me. I understand that I will need to notify Virginia Tech/College of Agriculture and Life Sciences if any changes to my situation occur that will impact this media release permission. PLEASE INITIAL YES__________ NO___________

www.ext.vt.edu

*18 USC 707

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Polytechnic Institute and State University, 2014 Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, genetic information, marital, family, or veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Jewel E. Hairston, Administrator, 1890 Extension Program, Virginia State, Petersburg. VT/0114/4H-224

IMMUNIZATION HISTORY Date of most recent tetanus shot: (month/year) _______________

HEALTH AND MEDICAL HISTORY Special Dietary Needs _________________________________________________________________________________________________ _________________________________________________________________________________________________ Do you have a history of any of the following? Check all that apply.

o

Allergies

o

Fainting spells

o

Wears Dentures

o

Asthma

o

Seizures/Convulsions

o

Surgery

o

Bleeding disorders

o

Heart condition

o

Serious illness/injury

o

Diabetes

o

Wears Contacts

Other__________________________________

Please describe any condition or need that you checked: ____________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Are you experiencing any current health problems, under medical care, receiving mental or behavioral services, or currently taking medication? If YES, please explain: ______________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Other information you feel important to share: ____________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

APPROVAL/EMERGENCY AUTHORIZATION I hereby give permission in the event of accident or injury for the medical staff or representative to secure proper treatment for, hospitalize, and to order injection and/or anesthesia and/or surgery for me. I understand that all attempts will be made to notify my emergency contacts of any such serious illness or injury. I hereby understand the nature and scope of the activities I am participating and agree to participate subject to limitations noted herein. This form may be photocopied for use outside of the event/activity location. ADULT PRINTED NAME:____________________________________________ SIGNATURE______________________________________________________ DATE_________________________ (Note: If for any reason you cannot sign this, you must contact your Extension office to obtain a legal waiver that must be signed.)

2006

publication 388-044

Standards of Behavior for Virginia 4-H Volunteers Trustworthiness, respect, responsibility, fairness, caring, and citizenship are the six core ethical values which the CHARACTER COUNTS! program calls the “Six Pillars of Character.” These values reflect those of the Virginia 4-H program and each 4-H member, volunteer, and staff member should strive to practice these values. The following standards for 4-H volunteers identify how these values will be reflected in volunteer performance. These standards help to ensure the safety and well-being of all 4-H participants and the integrity of the 4-H program. q I will teach, enforce, advocate, and model the Six Pillars of Character, which are trustworthiness, respect, responsibility, fairness, caring, and citizenship. q I will represent the Virginia 4-H program by conducting myself with courteous manners and language, exhibiting good sportsmanship, serving as a positive role model, and demonstrating reasonable conflict resolution skills. q I will dress in a manner that is appropriate for a given 4-H program/event in accordance with that program/event’s dress code. q I will support and promote the Virginia 4-H mission, “To develop youth and adults working with those youth to realize their full potential – becoming effective, contributing citizens through participation in research-based, non-formal, hands-on educational experiences.” q I will actively participate in, and complete, Virginia 4-H program orientation and training that prepares me to satisfactorily accomplish the tasks for which I have volunteered. q I will abide by all applicable laws and Virginia 4-H program policies, guidelines, and procedures. This includes, but is not limited to those regarding, child abuse, risk management, above suspicion, substance abuse, and limits of authority. q I will accept supervision and support from salaried 4-H Extension staff or designated management volunteers and understand that I work under the guidance, supervision, and leadership of the Extension staff in charge. q I will handle 4-H funds and engage in 4-H fundraising (when applicable) in an ethical manner.

q I will make all reasonable efforts to ensure that programs are accessible to all individuals regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. An equal opportunity/affirmative action employer. q I will not use (or allow others to use) alcohol or illegal drugs at any 4-H program or event. I understand that tobacco products can only be used in approved areas at approved times during approved events if I am of legal age. I understand the Virginia 4-H Search and Seizure policy regarding alcohol, drugs, or weapons. q I will, when transporting youth, operate motor vehicles and other equipment in a safe and reliable manner and only with a valid operator’s license in accordance with Virginia Tech and Virginia 4-H policies. I will comply with all motor vehicle-related state regulations and laws. All transported youth will be secured by properly operating seat belts when applicable. q I will conduct myself in a manner that is in the best interest of youth and the Virginia 4-H program and will not use the volunteer position for purposes of private or personal gain. q When applicable to my 4-H responsibilities, I will treat animals in a humane manner and teach program participants to provide appropriate animal care and management. q I will use technology in an appropriate manner in accordance with 4-H, Virginia Cooperative Extension, and Virginia Tech policies. q I will complete all necessary paperwork in a timely manner.

I understand that these standards represent a contractual agreement between volunteers and the Virginia 4-H program (of Virginia Cooperative Extension and Virginia Tech). My signature below indicates that I have read, understand, and agree to abide by these standards for volunteers. I understand that immediate suspension or termination of my position as a volunteer could result if I do not meet these standards.

VOLUNTEER (Print) VOLUNTEER SIGNATURE DATE EXTENSION SUPERVISOR (Print)

SUPERVISOR SIGNATURE

DATE

PARENT/GUARDIAN (Print)

PARENT/GUARDIAN SIGNATURE

DATE

(NOTE: This line must be signed for volunteers under 18 years old.)

www.ext.vt.edu Produced by Agriculture and Extension Communications, Virginia Tech

VIRGINIA POLYTECHNIC INSTITUTE AND STATE UNIVERSITY

Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Mark A. McCann, Interim Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Alma C. Hobbs, Administrator, 1890 Extension Program, Virginia State, Petersburg. VT/0305/W/426109

VIRGINIA STATE UNIVERSITY