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2. 
4. Volunteer Registration Record - Ongoing Volunteers
   Daggett County Department of Human Resources
6. Applicant Information
8. Volunteer Position(s) Desired*
10. Volunteer Name (Last, First, Middle Name)*
11. Birth Date*
    Birth Date
13. Home Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Email Address*
22. Do you have a Valid Utah Driver's License?*

    1. Yes
    2. No
24. Emergency Contact Name*
25. Emergency Contact Phone Number*
27. Have you been identified as a perpetrator of child abuse or neglect?*

    1. Yes
    2. No
29. Have you been convicted of a felony?*

    1. Yes
    2. No
31. Do you have a felony charge pending?*

    1. Yes
    2. No
33. Have you been convicted of a misdeamor?*

    1. Yes
    2. No
35. Have you received any moving traffic violations in the last 2 years?*

    1. Yes
    2. No
37. Education
39. If Yes, Explain:
41. Highest grade completed:*
42. High School Diploma or GED?*

    1. Yes
    2. No
44. Employment/Volunteer History
46. Paid Position: *
    Name, address and phone of current or most recent employer.
48. If currently employed, may we contact you at work?*

    1. Yes
    2. No
50. Does Daggett County have your permission to contact your employer or volunteer organization?*

    1. Yes
    2. No
52. My skills and interests include:
54. Describe Volunteer Experiences:
56. References
58. Reference 1*
59. Relationship*
60. Address
61. Phone Number*
63. Reference 2*
64. Relationship*
65. Address
66. Phone Number*
68. Reference 3*
69. Relationship*
70. Address
71. Phone Number*
73. Daggett County has my permission to contact references, and to do a criminal record check, a Children's Protective Services and a driving record check.*

    1. I give my permission for this request.
75. By submitting electronically, I am confirming I am not a minor and I am electronically signing with my consent and authority.*

    1. I am not a minor.
    2. I am the minor's parent/guardian and I give this minor my consent to volunteer for this position.
76. Date Submitting*
    Date Submitting
78. If this applicant is a Minor, parent or guardian name:
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit Submit and Print

* indicates a required field