4h673 Kansas 4h Volunteer Service Application
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4Kansas
Kansas 4-H Volunteer Service Application
A Registered 4-H Volunteer is a volunteer who has com-
Kansas 4-H Youth Development uses unique strategies and
opportunities to engage youth in reaching their full poten-
pleted the full Volunteer Information Profile (VIP) screening
tial through partnerships with caring adults. Volunteers are
process including: application, screening, and orientation
fundamental to the 4-H program and the accomplishment
and has been appointed by the appropriate K-State Re-
search and Extension Unit Board.
of the Kansas 4-H mission.
A 4-H volunteer is a non-paid representative of the local
To the extent authorized and allowed by law, this application
K-State Research and Extension unit for which they provide
form and its contents will be kept confidential and accessible
services.
only to extension personnel and members of the local review
committee and local K-State Research and Extension Board.
Please complete in ink or on a computer and print a copy.
K-State Research and Extension takes its obligation seriously to provide a safe environment for all persons involved in 4-H
Youth Development activities. Answers given by the applicant are to be verified in those instances where a legitimate ques-
tion arises as to his/her qualifications.
I. General Information
Name _________________________________________________________________________________________________
(First)
(Middle Initial)
(Last)
Mailing Address _________________________________________________________________________________________
(Street, Box, Route, Apt#)
(City)
(State)
(Zip)
Email: _________________________________________________________________________________________________
Check the best number to use.
Phone: ¨ Home _______________________ ¨ Work _______________________________
¨ Cell ____________________________________________ Text OK? ¨ Yes ¨ No ¨ Provider _______________________
Physical Address (If Different Than Above) ____________________________________________________________________
(Street, Box, Route, Apt#)
(City)
(State)
(Zip)
How long have you been at this present address? _______Years
If less than 5 years, list your prior addresses and the length of time you lived at each.
______________________________________________________________________________________________________
(Street, Route, Box, Apt #)
(City)
(State) (Zip)
(Length Of Stay)
______________________________________________________________________________________________________
(Street, Route, Box, Apt #)
(City)
(State) (Zip)
(Length Of Stay)
Volunteer Interest
(The following is for record-keeping purposes only.)
Check One Ethnicity:
Hispanic
Non-Hispanic
¨ Check here if you do not have a volunteer role selected
¨
¨
and need more information about 4-H Volunteer positions.
Gender:
Female
Male
¨
¨
To assist in matching you to an available volunteer role,
Residence
¨ Farm ¨ Town< 10K
¨ Town 10K – 50K
please obtain and fill out a 4-H Volunteer Matching Informa-
¨ Suburbs >50K
¨ Cities >50K
tion Form available from the Extension Office.
Check all that apply: Race:
¨ Asian
¨ White
Do you wish to serve as a volunteer for an existing club?
¨ Black
¨ American Indian/Alaska Native
¨ Yes
¨ No
¨ Hawaiian/Pacific Islander
If yes, name of Club and role:__________________________
Do you have special needs?
__________________________________________________
If yes, please describe: _______________________________
Are you a 4-H alumnus? ¨ No ¨ Yes
II. Personal Information
Where? ___________________________________________
Is your driver’s license current and valid?
Yes
No
¨
¨
Current or previous Volunteer Experience (List current or
Date of Birth _______________________________________
most recent experience first)
Driver’s License # ___________________________________
__________________________________________________
Organization
Volunteer Role
Year(s)
Do you currently have vehicle insurance coverage as re-
__________________________________________________
quired by the State of Kansas?
Yes
No
¨
¨
Organization
Volunteer Role
Year(s)
Kansas State University Agricultural Experiment Station and Cooperative Extension Service
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