Sciworks Volunteer Application Form – Fill Out and Use This PDF

VOLUNTEER APPLICATION

Thank you for your interest in becoming a volunteer with SciWorks.

Please leave the completed application with a front desk employee or mail your forms to Volunteer Coordinator, SciWorks, 400 West Hanes Mill Road, Winston-Salem, NC 27105. If you have any questions please contact Patty Langston, Volunteer Coordinator, at (336) 714-7114 or plangston@sciworks.org.

*Youth volunteers must be at least 14 years of age. (Subject to Coordinator’s Discretion)

Date: ____/_____/_____

Name: _____________________________________________________________________

Address: ___________________________________________________________________

City: ____________________________State: ____________________ Zip: _____________

Home Phone #: ___________ Cell Phone #: ___________ Alternate Phone #: ___________

E-mail Address: ______________________________ (e-mail blasts of events are sent regularly)

Birth Date: ______/______/______			Age (if under 18): _______
Month	Day	Year

Have you ever been convicted or do you have any pending rulings regarding a felony or misdemeanor? Y/N

If yes please explain:

How did you hear about SciWorks’ Volunteer Program?

Please list two references (personal, workplace, church or service group, NON-RELATIVE) Name: ______________________ Phone #: ______________ Relationship: ____________

Name: ______________________ Phone #: ______________ Relationship: ____________

For office use only: Dates of Contact

Rev. 9/30/2012

Special Skills:

Special Interests:

Volunteer or pertinent experience:

What do you hope to gain by volunteering at SciWorks?

Do you or your family have an existing SciWorks Membership?

Do you or any of your family belong to service groups? (Rotary, Lions Club, Kiwanis, etc.)

Within your circle of influence, is there anyone who may want to volunteer or partner financially with SciWorks?

Additional Information (such as medical or physical limitations or other information):

Rev. 9/30/2012

Brief Job Descriptions for Volunteers

Please check the area(s) where you are most interested in volunteering. Upon receiving your application, the Volunteer Coordinator will set up an appointment for orientation. If you choose not to participate at such time, your application will be held for 1 year only. You will receive training in the area assigned however; you must be willing to help in other areas as needs arise

*Not all areas may have openings.

Education/Administration—Help staff prepare materials (photocopy, cut, fold, staple, etc…) for classes mailings, filing and camps.

Science Demonstration Assistant—Help visitors learn more about the interactive exhibits, use science demonstration carts throughout the museum and assist educators. Volunteers seeking this be comfortable presenting to the public.

Second Saturday Science—Assist with activities designed for families on the 2nd Saturday of each month.

Special Events—Help educators and staff with various special events throughout the year. Assist with decorations, food, crafts, etc.

BioWorks*—Assist staff with the maintenance of program animals, clean cages, clean holding areas, feed the animals, etc. Help with marine aquaria by cleaning tanks and filters and assisting with regular water changes. This volunteer opportunity requires a weekly to bimonthly commitment.

Environmental Park*—Help with the maintenance of the park and barnyard area, including feeding animals and cleaning and grooming. Volunteers work rain or shine. This volunteer opportunity requires a weekly to bimonthly commitment.

Garden*—Spread mulch, weed, water and clear invasive species in the environmental park. This volunteer opportunity requires a weekly to bimonthly commitment.

Summer Camp*—Help with SciCamp during June, July and August. Assist teachers with activities, crafts, games, snack, set-up and clean-up, etc. Volunteers helping with SciCamp must be available Monday-Friday of the week(s) they are scheduled to volunteer. Youth volunteers may help with 1-2 weeks of camp each summer. Volunteer placement for SciCamp begins in early May.

*These positions are often filled quickly and rarely have openings. We do try to be as accommodating as possible.

Please understand we are looking for dedicated people to help SciWorks continue on its path to be in the top 10 Science Centers of the Nation. We cannot do that without dedicated volunteers. We welcome Crosby Scholars and other students who are fulfilling requirements for Senior/School Projects and Scouts. We do NOT accept court mandated community service, as that is not volunteering. If you are volunteering simply to fulfill a 2-5 hour requirement, you might want to reconsider.

Rev. 9/30/2012

VOLUNTEER

MEDICAL RELEASE AND

EMERGENCY AUTHORIZATION

Volunteer’s Name _______________________________________________________________________

Address ________________________________________________________________________________

Street	City	State	Zip
Telephone ________________	Birth Date ________________	Age (if under 18) _____

In consideration for the Volunteer’s right to participate in the Volunteer Program of SciWorks, The Science

Center and Environmental Park of Forsyth County (hereafter “SciWorks”), the Undersigned hereby:

(I)Assumes all responsibility for medical treatment and insurance to cover any injury or illness occurring to Volunteer while volunteering for SciWorks, and

(II)Holds SciWorks harmless from any and all liability, actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, which arise from or in connection with volunteer activities of Volunteer, and

(III)Voluntarily assumes all risks which the Volunteer may take in participating in the SciWorks Volunteer Program.

The Undersigned understands that the Volunteer is covered by SciWorks’ liability insurance, but not by health insurance, accident insurance, life insurance, workman’s compensation, or social security through the Center.

The Undersigned and Volunteer further understand that if a staff supervisor request the Volunteer to perform a task that exceeds the Volunteer’s physical capabilities, the volunteer is responsible for declining that task.

Physical limitations preventing the Volunteer from performing certain kinds of work are as follows:

(SciWorks medical release form—1 of 2)

Rev. 9/30/2012

In case of emergency, the undersigned requests that SciWorks notify:

Name	Relationship to Volunteer
Weekday Telephone Number	Weekend Telephone Number

In the event that reasonable attempts to contact the above are unsuccessful, the Undersigned hereby gives consent for the administration of any treatment deemed necessary by the following designated practitioner:

_________________________ at telephone number _______________.

In the event that the designated practitioner is not available, the Undersigned gives consent for the administration of any treatment deemed necessary by an alternate physician and the transfer of the Volunteer to

_____________________________ (preferred hospital), or any other hospital reasonably accessible.

Such consent does not cover major surgery unless the medical opinion of two other licensed physicians, concurring in the necessity of such surgery, are obtained before the surgery is performed.

Facts, concerning medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted are as follows.

_______________________________________________________________________________________

_______________________________________________________________________________________

The Volunteer is covered by personal health and accidental injury insurance as indicated below:

Name of Insurance Company

Policy Number

As used herein, SciWorks includes all facilities whether indoor or outdoor, all exhibits, and all visitors, agents, employees, directors, members, volunteers, and sponsors. As used herein, the Undersigned is the Volunteer, or if the Volunteer is less than eighteen years old, then the Undersigned is the parent or guardian of the Volunteer.

Volunteer SignatureDate

_______________________________________ has my permission to participate in the SciWorks Volunteer

Program. I understand that my child is expected to behave maturely and to follow the Museum guidelines.

Parent of Guardian Signature	Date
	(SciWorks medical release form —2 of 2)

Rev. 9/30/2012