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If more room is needed, provide additional offense information in attached page(s).

A conviction record will not necessarily bar you from volunteer work. Factors such as nature of offense, date, and relationship between the offense and the position for which you are applying will be considered. However, a false statement or omission of any information will bar future volunteer work.

The statements made by me in this application are true and complete to the best of my knowledge, and I understand it is subject to verification by the City of Keene. I understand that any false information, omissions of facts or misrepresentations may disqualify me from volunteer work with the City of Keene or immediate release from volunteer work.

I understand that a criminal history check will be administered as well as verification of any information provided as part of the volunteer process, such as reference checks, etc.

By signing below, I certify that I have read and agree with these statements.

I voluntarily assume full responsibility for any risk of loss, property damage or personal injury that may be sustained by me by participating in such activity.

For myself, my heirs, assigns, representatives and anyone else claiming on behalf of or through me, I hereby release, indemnify, and hold harmless the city, and its officers, servants, agents, or employees from any and all liability, claims, demands, actions, and causes of action (including claims for court costs and attorney’s fees) whatsoever arising out of or related to any loss, damage or injury, including death, that may be sustained by me or to any property belonging to me, whether caused by the negligence of the city or otherwise, while volunteering, or while in, on or upon any city premises.

In the event that I am placed as a volunteer with the City of Keene, I understand that I will be required to comply with all of the City’s rules, policies and regulations.

I fully understand that if my services are no longer needed, or my performance is not acceptable, for any reason, the City of Keene has the right to terminate my services as volunteer at any time, with or without notice.

Volunteers must notify the City of Keene of any injury that occurs while performing volunteer duties for the City of Keene, The City of Keene is a member of the Political Subdivision Workers' Compensation Alliance (PWSCA) and volunteers must seek treatment for an on-the-job injury from a doctor on the approved list. Therefore, for coordination of doctor visits, volunteers must immediately report to their supervisor or contact Human Resources at 817-641-3336 or 682-970-0970. Failure to see a doctor on the approved list may lead to the claim not being paid. In an emergency, volunteers may be treated at any emergency facility.

I specifically acknowledge that:
• I shall receive no compensation whatsoever for performing work for and on behalf of the City. All activities observed, undertaken or performed by me shall be performed without promise, expectation or receipt of compensation for services rendered and without expectation, promise, or representation, expressed or implied, of employment with the City of Keene.
• During my service for and on behalf of the City I may be privy to confidential and sensitive information. I understand and agree that privileged and confidential information shall not be repeated, disseminated or disclosed by me in any manner and that if I breach the confidentiality of the City, my services as a volunteer will be terminated, and that I may be subject to civil and/or criminal sanctions.
• I understand that I may be required to submit to and successfully pass a medical examination and/or drug test by a physician and laboratory selected by and at the expense of the City of Keene in case of serious accident, injury, or death related to my service as a volunteer.
• Volunteers under the age of 18 will be required to have a parent or legal guardian complete a Minor Work Release form.

By signing below, I acknowledge and represent that I have read the foregoing, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements or inducement, apart from the foregoing written agreement, have been made; I am fully competent; and I execute this agreement for full, adequate and complete consideration fully intending to be bound by the same.

Note: Under the age of 18 are only eligible to perform office work.

Volunteers are expected to be with a parent or guardian if under the age of 14 years. The parent/guardian shall be with the child and accessible to their needs at all times.

I hereby certify that I am the parent or guardian of the minor named above. I have the legal right to consent to and do consent to the terms and conditions of this release.

A person 14 or 15 year of age may not work more than 8 hours in one day or more than 48 hours in a week. They also may not work between the hours of 10 p.m. and 5 a.m. on a day that is followed by a school day or between the hours of midnight and 5 a.m. on a day that is not followed by a school day. A person who is 14 or 15 years of age may not work between the hours of midnight and 5 a.m. on any day that school is recessed for the summer. They may only work between 7 a.m. and 7 p.m. during the school year and between June I and Labor Day, between the hours of 7 a.m. and 9 p.m.

A child 16 or 17 year of age have no restrictions on the number of hours or times of day they may work. A child who is 14 or 15 may be employed in retail, food service, office/clerical, and maintenance of grounds (but not to include the use of power-driven mowers or cutters).

Persons who are 14 to 17 years old may not perform duties which the Secretary of Labor may find and declare to be hazardous or detrimental to their health or well-being.

Persons who are 14 to 15 years old are prohibited from work that includes:
• Construction; including demolition and repair
• Work requiring the use of ladders or scaffolds
• Cooking; including the use of electric/gas grilles, deep fryers, grinders, food slicers, food choppers, cutters, and bakery type mixers
• Baking
• Work in freezers and meat coolers and all work in the preparation of meat for sale
• Loading or unloading goods to and from trucks, railroad cars, or conveyors
• All work in warehouses except office and clerical
• Operating power-driven mowers or cutters

Persons who are 14 to 17 years old are prohibited from work that includes:

• Driving a motor vehicle on any public road or highway or servicing a motor vehicle
• Operating or assisting to operate power driven woodworking machines
• Operating or assisting to operate power driven hoisting apparatus such as elevators, cranes, hoists, and high-lift trucks
• Operating or assisting to operate power driven metal forming, punching, and shearing machines
• Operating or assisting to operate power driven meat processing machines
• Operating or assisting to operate power driven bakery machines
• Operating or assisting to operate power driven circular saws, band saws, and guillotine shears
• Roofing operations and work on or about a roof
• Excavation operations