Texas A&M AgriLife Extension Service

Denton County Government Center

401 W. Hickory, Suite 125

Denton, Texas 76201

Metro: 940-349-2883

Fax: 940-349-2881

APPLICATION FOR MEMBERSHIP

Save a copy of this application to your computer before completing. It will not save to the website. You must bring this application, Volunteer Application Form, and $150.00 check made out to EFCMN (Elm Fork Chapter Master Naturalist) to the AgriLife Extension Office or mail it to EFCMN 2017 Class at the above address.

Please type or print clearly. Return your completed application, Volunteer Application Form, and check made out to EFCMN for $150 to the AgriLife Extension Office by August 7th, 2017.

Use additional paper when necessary.

Name (please print)	I prefer to be called

Mailing Address: Street / Apt / P O Box

City	County	State	ZIP

Home phone: _____________________________________ cell phone _____________________________________ Please check which is preferred

Email address _________________________________________

Emergency Contact ___________________________________________________________________________________________

name relationship main phone alternate phone

What is your profession? ______________________________________________________________________________________

Are you employed ____ full time ____ part-time ____ retire

Place of Employment __________________________________________________________________________________________

How did you hear about this class? ________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Your areas of VOLUNTEER INTEREST: Rate as HIGH, MEDIUM or LOW - If you have experience or training in this area, please also check experience box.

High	Medium	Low	Have experience?
Trail Guide - Leading nature hikes/walks
Trail Maintenance
Removal of invasive plant species (privet, Johnson grass, etc)
Native Plant and habitat rescue
Collecting native wildflower and grass plants and seeds
Identifying trees and other plants
Urban Forestry
Native Prairies
Wetlands
Bird and wildlife census
School habitats (butterfly gardens, outdoor learning areas)
Creating and maintaining wildscapes
Public outreach: booths at public events
Public outreach: Presentations
Citizen Scientist Projects (ex. species monitoring)
Wildlife Management (rescue, surveys, hotline, bird banding, etc)
Educating adults and/or children about nature
Working with children/youth in outdoor setting
Working with children/youth in classroom setting
Working with Junior Master Naturalist program
Nature Photography
Working with AV System & technology (for meetings, events)
Hospitality (organizing social or refreshments for meetings and events)
Maintaining volunteer records
Computer work
Working with special events
Working on newsletter
Writing articles for newsletter
Website - working on website
Fundraising/writing grants
Publicity
Scrapbooking

Is there anything you'd like to add that we haven't asked about? ____________________________________

________________________________________________________________________________________

I am 18 years of age, or older.

I will be available for the weeks of classes conducted from 9 a.m. - 3 p.m. every Tuesday

beginning August 29, 2017 continuing through November 14, 2017.

I understand I am required to attend a minimum of 60 hours of Basic Training,

plus 8 hours Advanced Training and to complete 40 hours of acceptable volunteer service

by December 31, 2018.

_______________________________	________________

Signature	Date

A TYPED OR SIGNED SIGNATURE INDICATES YOUR ACKNOWLEDGEMENT.

Goals of the Texas Master NaturalistTM program

To provide service to the community through public educational programs that promote understanding and conservation of our natural resources, fosters an appreciation of the diversity of our plant and animal species and promotes stewardship and conservation of our natural environment; and

To provide opportunities for Texas Master NaturalistTM to use and expand their knowledge and skills in ways that will benefit and interest the volunteers and promote the Texas Master NaturalistTM program.

Volunteer Pledge:

I understand that in exchange for the training made possible through the Texas Master NaturalistTM program, I will volunteer at least forty (40) hours of my time to the Texas Master NaturalistTM program within one year and I will complete the annual continuing education requirements. I understand that I will become a Certified Texas Master NaturalistTM when I complete both the training and volunteer work.

Signature	Date

A TYPED OR SIGNED SIGNATURE INDICATES YOUR ACKNOWLEDGEMENT.

If you have any questions, please contact the Denton County, Texas A&M AgriLife Extension Service Office: Metro: 940-349-2883

:

Be sure to return your application, Volunteer Application Form and check

no later than August 7th, 2017.

Enrollment is limited.

You must bring this application, the Volunteer Application Form, and $150.00 check made out to EFCMN

to the AgriLife Extension Office or mail it to EFCMN 2017 Class at 401 W Hickory, Suite 125, Denton, Texas, 76201. We must have all of this to reserve your place in the 2017 class. Class size is limited to 30 people. To learn more, check us out: http://txmn.org/elmfork

Educational programs of the Texas A&M AgriLife Extension Service are open to all people without regard to race, color, sex, religion, disability, age (must be 18 years of age or older), or national origin. Individuals who require an auxiliary aid, service or accommodation in order to participate in Extension sponsored programs are encouraged to contact the County Extension office to determine how reasonable accommodations can-be-made.

CONFIDENTIAL

E-446 7/10

Volunteer Application Form

And consent for criminal background history check authorization/waiver

To be completed by Extension program volunteers (EFNEP, BLT, etc.) and Master Volunteers only.

4-H volunteers must register online via 4-H CONNECT or by completing the 4-H Adult Volunteer Application (4-H 2-1.056)

Please print:

DENTON

1. APPLICANT’S FULL, LEGAL NAME	2. COUNTY

3. ADDRESS	4. CITY	ZIP

/	/

5. FIRST 5 DIGITS OF SOCIAL SECURITY NUMBER	6. DATE OF BIRTH

7. DRIVER’S LICENSE NUMBER (optional)	8. GENDER (circle one)	Male / Female

MASTER NATURALIST

9. Are you of Hispanic ethnicity? Yes / No	10. VOLUNTEER PROGRAM AREA RACE (circle one) White / Black / Asian / American Indian / Alaskan Native / Native Hawaiian / Pacific Islander

Please sign at the bottom of the form.

I hereby authorize veriFYI and/or its Service Provider and the Texas AgriLife Extension Service to request and receive any and all background information about or concerning me, including, but not limited to, my Criminal History, Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers. I authorize the Texas AgriLife Extension Service or any of its components to make reference checks relating to my volunteer service. I understand that this information will be used to determine my eligibility as a volunteer/employee with the Texas AgriLife Extension Service.

The criminal history, as received from the reporting agencies, may include arrest and conviction data, as well as plea bargains and deferred adjudications and delinquent conduct committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/ volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available

for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged.

I further release and discharge veriFYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization and/or procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable.

I understand that I have the right to make written request within a reasonable period of time to veriFYI for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.

Date	13. Applicant’s Signature

Volunteer Application Form Instructions

Applicant’s Printed Name – Complete with first name, middle name and last name.

County – Complete with the county name in which you are applying to be a volunteer.

3/4. Address – Complete with your current mailing address, city and zip code.

Social Security Number – Complete with at least the first five digits of the social security number. The social security number is an individual descriptor that enables the system to complete a national criminal search of 47 jurisdictions.

Date of Birth – Complete with the month, day and year of birth.

Driver’s License Number – Complete with current driver’s license number and state. Although optional, this helps affirm your identity during a background check.

Gender – Complete by circling one of the options.

Race – Complete the race and ethnicity section by circling the answers that apply. This field is optional; however, it is very important in confirming accurate identity.

Volunteer Program Area – Complete with the program area you are volunteering for (e.g., Better Living for Texans, Expanded Food and Nutrition Education Program, Master Gardener, Master Naturalist, Master Wellness Volunteer).

*4-H volunteers should complete the Texas 4-H Adult Volunteer Application (4-H 2-1.056).

Authorization Statement – State agencies screening volunteers are required by legislation to use the Volunteer Center of North Texas. The Volunteer Center contracts with VeriFYI. VeriFYI is a background verification software system that accesses multi-jurisdiction checks utilizing one of the largest private-sector criminal history databases in the nation (180 million records). All information received is held in confidence and not shared at the county level. Criminal record results are shredded when a volunteer’s status is determined.

Date Completed __________________________________________

Applicant’s Signature _________________________________________________________________