I.  General Information:

Name:
FirstMiddleLast

Mailing Address:
StreetCityZip Code

County Number of years living at this address

Date of Birth:  MonthDayYear

Social Security Number:

Do you possess a valid drivers license?  Yes No

Have you had a DWI conviction in the past 10 years?Yes No
If yes, in what year(s):

Phone:  Day Best time to call
      Evening Best time to call

Are you a 4-H alumnus?  Yes No 
Where? (County/State)

II.  Volunteer Service Record:

Have you ever been a 4-H volunteer? Yes No 
If yes, how many years?
How many years have you served as a 4-H:
   Organizational Leader      Committee Member
   Key Leader/Middle Manager  Project Leader
   Club/School Group Volunteer   Other (describe)

III.  References:  Friends, Volunteer Agency or Employers (No family members or relatives.)

Name:
Address:
Telephone:Relationship to you:

Name:
Address:
Telephone:Relationship to you:

Have you ever voluntarily or involuntarily been terminated as a volunteer?  Yes No 
  If yes, when and why?
  Have you ever been convicted of a criminal offense? (do not include
  minor traffic violations) Yes No  If yes, please give date, nature of
  offense, and disposition.
(A criminal record will not necessarily bar an applicant; a criminal record will be considered as it relates to the specifics of the position to which you have applied.)

IV.  Health & Medication:

   The health and well being of 4-H members and volunteers is the highest concern of the 4-H Program.  The following questions relate to conditions which may impact on the safety and well being of participants and volunteers.  Conditions which require ongoing medication (high blood pressure, diabetes, etc. or allergic reactions to medications, bites or stings) are among the conditions which may require special concerns or reactions by others. 
   In the most severe situation a doctor's release may be required to participate in some or all activities. 

Are you under a doctor's care?  Yes No
  Explain

Are you taking prescription drugs? Yes No
  Explain

V.  Experiences in Wildlife and Shooting Sports

   4-H Shooting Sports volunteers have come equally from two areas; those with a strong 4-H background and those who have a strong shooting background.  Cross certification with groups as divergent as Boy Scouts, the National Rifle Association, the National Muzzleloading Rifle Association, and the New York State Department of Environmental Conservation have prepared instructors for their role in training youth in an informal educational setting.  Please include any certification or experiences that might relate to your involvement as a 4-H Shooting Sports Instructor.  Please include current and past certification, with the name of the groups and the ranking you held.

VI.  Standard of Behavior:

   4-H volunteers in the 4-H Shooting Sports Program are recruited to serve a one year term.  Upon successful completion of one year (the 4-H year is from October 1 to September 30) service will continue if agreed upon by both the volunteer and 4-H.  Non-renewal of the volunteer agreement will not require explanation on the part of either the volunteer or the 4-H representative.
   The Standards of Behavior is an agreement which must be accepted by volunteers serving in the program.  The Standards shall guide their behavior during their involvement in the 4-H Youth Development Program.
   The New York State 4-H Shooting Sports Program of Cornell Cooperative Extension provides quality educational programs accessible to all New York youth.  The primary purpose of the Standard of Behavior is to ensure the safety and well-being of all 4-H participants (i.e., members, their parents and families, professionals, and volunteers).  4-H volunteers are expected to function within the guidelines of New York Cornell Cooperative Extension and the 4-H Shooting Sports Program.  4-H volunteers shall be individuals of personal integrity.

4-H Volunteers will:

• Uphold volunteerism as an effective way to meet the needs of youth and adults

• Uphold an individual's right to dignity, self-development, and self-direction

• Accept the responsibility to represent their individual county 4-H program and the New York 4-H Youth Development Program with dignity and pride by being positive mentors for the youth with whom they work

• Conduct themselves in a courteous and respectful manner, exhibit good sportsmanship, and provide positive role models for all youth

• Respect, adhere to, and enforce the rules, policies, and guidelines established by the Saratoga 4-H Shooting Sports Program and Cornell Cooperative Extension

• Not commit a felonious criminal act

• Comply with equal opportunity and anti-discrimination laws

• Perform duties in a responsible and timely manner

• Report immediately any threats to the volunteer's emotional or physical well-being to professional 4-H staff

• Accept the responsibility to promote and support 4-H in order to develop an effective county, state, and national program

• Handle animals and operate machinery, vehicles, and other equipment in a responsible manner

VII.  Signature:

   The above information is correct to the best of my knowledge.  I understand that the misrepresentation or omission of information requested is just cause for non-appointment or termination as a 4-H volunteer.  I authorize Cornell Cooperative Extension to obtain from all persons and/or agencies my records, documents and other information relative to my suitability to perform the duties of the volunteer position.  I further release all parties supplying information form all liability and responsibility arising from their supplying said information.
   If appointed as a volunteer I agree to abide by the policies of the 4-H Shooting Sports Program and the 4-H Youth Development Program of Cornell Cooperative Extension.

Signature_________________________________ Date______________