4h673 Kansas 4h Volunteer Service Application Page 2
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4-H is very concerned that volunteers be appropriate role
models for youth participants.
List three adults who are familiar with your character and
Please complete all questions. A “yes” does not automatically
your qualifications as it relates to working with youth. (Do
exclude you from becoming a registered volunteer.
not list family members or Extension Agents.) Please in-
Have you ever had any problems with: Check all that apply:
clude complete mailing address, phone, and email address.
a. substance abuse: alcohol, tobacco or other drugs ?
References will be contacted. Information received from
¨ No ¨ Yes If Yes: ¨ Charged ¨ Convicted
references will not be accessible to applicants.
b. criminal behavior: Felony or Misdemeanor
¨ No ¨ Yes If Yes: ¨ Charged ¨ Convicted
1. ________________________________________________
c. child abuse or neglect:
(Name)
(Phone: Day & Night)
(Association To You)
¨ No ¨ Yes If Yes: ¨ Charged ¨ Convicted
__________________________________________________
(Street, Route, Box, Apt#)
(City)
(State)
(Zip)
Have you ever had your driver’s license suspended or re-
voked? ¨ No ¨ Yes
Email address (preferred) _____________________________
If yes, to any of the above, please elaborate: _____________
__________________________________________________
2. ________________________________________________
__________________________________________________
(Name)
(Phone: Day & Night)
(Association To You)
__________________________________________________
If yes to any of the above, please describe what steps you
(Street, Route, Box, Apt#)
(City)
(State)
(Zip)
have taken to correct the problem(s):
__________________________________________________
Email address (preferred) _____________________________
__________________________________________________
Other than the above, is there any other fact or circum-
3. ________________________________________________
stance involving you or your background that would affect
(Name)
(Phone: Day & Night)
(Association To You)
your ability to be entrusted with the supervision, guidance
__________________________________________________
and care of youth under the age of 19?
(Street, Route, Box, Apt#)
(City)
(State)
(Zip)
¨ No ¨ Yes
(If yes, please explain): ___________________
__________________________________________________
Email address (preferred) _____________________________
__________________________________________________
Please add additional pages as necessary.
Signature Required
I understand that:
a. I affirm the information I have given on this form is true, correct, and complete. The information I have provided may
be verified by contacting persons or organizations named in this application or by contacting any person or organi-
zation that may have information concerning my qualifications. I further waive the right to ever view, inquire into, or
learn the substance and/or content of any reference given by any individual with regard to any aspect of this applica-
tion. I hereby release and agree to hold harmless from liability any person or organization that provides information. I
also agree to hold harmless the 4-H Club, local Extension Unit, Kansas State University, and the officers, employees, and
volunteers thereof with respect to such information.
b. I have read and agree to abide by the Kansas 4-H Volunteer Code of Ethics. I agree to comply with the policies, rules,
and regulations of the 4-H Youth Development program and local Extension Unit. I agree to complete an orientation.
In signing this application, I apply for appointment and registration as a 4-H Volunteer with the local Extension Unit
and the Kansas 4-H Youth Development Program.
c. As a 4-H Volunteer I serve at the request of the local Extension Unit and may be removed from service at its discre-
tion. I may resign my volunteer role at any time at my discretion.
Signature ______________________________________________________________ Date _______________________
Parental Signature (if under age 18)_________________________________________ Date________________________
Upon Completion, Return this Form in a Sealed Envelope to the Local Extension Unit Office
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K-State Research and Extension
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