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City Committee / Commission Appointment Application

2. Select the Board, Commission, or Committee applying for*
   -- Select One --Select OneMayorCity CouncilBikeways/Walkways CommitteeBudget CommitteeCollaborative Economic Development CommitteeCommittee on Public Art (CoPA)Historical Buildings and Sites CommissionHousing Advisory CommitteeParks Advisory CommitteePAVE CommitteeTourism Advisory CommitteeUrban Planning CommissionUrban Tree Advisory Committee

3. Wait List

   1. Put me on a wait list if there are no current openings

5. Personal Information
   Enter your personal information.

   Enter your personal information.

7. First Name*

8. Last Name*

10. Address*

12. Mailing Address (if different)

14. Home Phone Number*

15. Business Phone Number

16. Years as City Resident*

18. Email Address

20. Occupation and Employer*

21. May we contact you at work?

    1. Yes
    2. No

23. Educational Background
    Enter your educational background.

    Enter your educational background.

25. High School

    1. Graduated
    2. GED

26. College

    1. Some College
    2. Bachelor Degree
    3. Advanced Degree

27. Trade or Business School

29. Have you ever been convicted of a felony?*

    1. Yes

    1. No

31. Relevant Job History

33. Previous Volunteer/Committee Experience

    Involvement with City or other government committees, boards, projects, etc.

35. Community Involvement

37. Authorization Waiver
    I have completed the above questions and to the best of my knowledge, what has been stated is true. If appointed, I agree to serve without reimbursement of any kind. I understand that I maybe subject to a criminal records check. I further understand that irrespective of any criminal records check, the City of Grants Pass may decline my volunteer application or volunteer services at any time.

    I have completed the above questions and to the best of my knowledge, what has been stated is true. If appointed, I agree to serve without reimbursement of any kind. I understand that I maybe subject to a criminal records check. I further understand that irrespective of any criminal records check, the City of Grants Pass may decline my volunteer application or volunteer services at any time.

39. Verification*

    Check the box and enter your name to verify the above information.

    1. I verify the information in my application.
41. Applicant's Name*

42. Date*
    Date

    Date

44. City Committee / Commission Appointment Questionnaire
    Fill out the following questions.

    Fill out the following questions.

46. Statement of your reasons for desiring to serve:

    Please write a brief narrative describing your interest, qualifications and what you hope to accomplish in this position. Please include your skills, experience, and knowledge that you would contribute in this position. You may attach a cover letter, resume, or other information.

48. Statement of any relevant concerns or goals to be achieved while serving in this position:

50. What do you think are the most critical issues facing this local government in the next three years?

52. Are there some things about the City of Grants Pass that you have a special interest in?

54. Additional Information

    You may attach a cover letter, resume, or other information.

56. Responsibilities of Volunteers
    As a volunteer with the City of Grants Pass, you are covered by the City of Grants Pass for liability and personal injury. Please read the following and sign:

    As a volunteer with the City of Grants Pass, you are covered by the City of Grants Pass for liability and personal injury. Please read the following and sign:

58. What if I am accused of doing something wrong?
    The city provides you with protection from liability for bodily injury or property damage you cause to someone else. We refer to this coverage as "Tort Liability." The coverage is subject to the following conditions:<br><br>1. You limit your actions to only the duties assigned in your job description, or assigned by an authorized supervisor. <br><br>2. You perform your assigned duties in good faith, and do not act in a manner that is reckless or with intention to cause harm to others.

    The city provides you with protection from liability for bodily injury or property damage you cause to someone else. We refer to this coverage as "Tort Liability." The coverage is subject to the following conditions:
    
    1. You limit your actions to only the duties assigned in your job description, or assigned by an authorized supervisor.
    
    2. You perform your assigned duties in good faith, and do not act in a manner that is reckless or with intention to cause harm to others.

60. You are personally responsible when:
    1. Your actions are contrary to the duties assigned in your job description, or assigned by an authorized supervisor. <br><br>2. You act maliciously, with the intent to cause unlawful damage or injury, or with gross recklessness. <br><br>3. You are accused of a crime. <br><br>4. You fail to cooperate with Risk Management or the City Attorney; or you act in such a way as to harm the City's defense against the claim.<br><br> The limits of this protection are as stated in the Oregon Tort Claims Act, ORS 30.260 through 30.300.

    1. Your actions are contrary to the duties assigned in your job description, or assigned by an authorized supervisor.
    
    2. You act maliciously, with the intent to cause unlawful damage or injury, or with gross recklessness.
    
    3. You are accused of a crime.
    
    4. You fail to cooperate with Risk Management or the City Attorney; or you act in such a way as to harm the City's defense against the claim.
    
    The limits of this protection are as stated in the Oregon Tort Claims Act, ORS 30.260 through 30.300.

62. What if I have an accident while driving a City vehicle?
    The City of Grants Pass will pay and defend claims against you for injury to people or property caused while operating a City owned vehicle to perform assigned duties. We refer to this coverage as "Vehicle Liability." The City will also pay for damages to the City vehicle.<br><br>Your insurance company will be responsible for the defense and payment of claims against you for injury to people or property caused while operating your personal vehicle.<br><br>The coverage is subject to the following conditions:<br><br>1. You report an accident that happens on City business to your supervisor immediately. <br><br>2. You cooperate fully with Risk Management and the City Attorney. <br><br>3. You have a valid driver's license, and follow all laws and rules while operating the vehicle.

    The City of Grants Pass will pay and defend claims against you for injury to people or property caused while operating a City owned vehicle to perform assigned duties. We refer to this coverage as "Vehicle Liability." The City will also pay for damages to the City vehicle.
    
    Your insurance company will be responsible for the defense and payment of claims against you for injury to people or property caused while operating your personal vehicle.
    
    The coverage is subject to the following conditions:
    
    1. You report an accident that happens on City business to your supervisor immediately.
    
    2. You cooperate fully with Risk Management and the City Attorney.
    
    3. You have a valid driver's license, and follow all laws and rules while operating the vehicle.

64. You are not covered for an accident while driving when:
    1. You operate your personally owned vehicle to perform City business. The City does not provide any protection for your vehicle. You are expected to have liability insurance, comprehensive & collision insurance for any personally owned vehicle that you use on City business. It is up to you to carry insurance on your vehicle. <br><br>2. You use a City vehicle or any other vehicle for personal use. The City does not provide any coverage if you drive a City vehicle or any other vehicle contrary to your job description or the directions of your supervisor. <br><br>The limits of this protection are as stated in the Oregon Tort Claims Act, ORS 30.260 through 30.300.

    1. You operate your personally owned vehicle to perform City business. The City does not provide any protection for your vehicle. You are expected to have liability insurance, comprehensive & collision insurance for any personally owned vehicle that you use on City business. It is up to you to carry insurance on your vehicle.
    
    2. You use a City vehicle or any other vehicle for personal use. The City does not provide any coverage if you drive a City vehicle or any other vehicle contrary to your job description or the directions of your supervisor.
    
    The limits of this protection are as stated in the Oregon Tort Claims Act, ORS 30.260 through 30.300.

66. What if I get hurt?
    The City does not provide Workers' Compensation benefits for Registered Volunteers. The City provides an accident insurance policy for Registered Volunteers. It is limited only to injuries due to an accident while performing assigned volunteer duties. The coverage is subject to the following conditions: <br><br>1. Coverage pays after any available insurance which may apply to the same injury. <br><br>2. If your are injured in a private vehicle, the vehicle owner's insurance is responsible for your medical bills. <br><br>3. The amount of Insurance applicable per Registered Volunteer is as follows: <br>a. Principal Sum - $2,500 <br> b. Capital Sum - $2,500 <br>c. Medical Indemnity - $25,000

    The City does not provide Workers' Compensation benefits for Registered Volunteers. The City provides an accident insurance policy for Registered Volunteers. It is limited only to injuries due to an accident while performing assigned volunteer duties. The coverage is subject to the following conditions:
    
    1. Coverage pays after any available insurance which may apply to the same injury.
    
    2. If your are injured in a private vehicle, the vehicle owner's insurance is responsible for your medical bills.
    
    3. The amount of Insurance applicable per Registered Volunteer is as follows:
    a. Principal Sum - $2,500
    b. Capital Sum - $2,500
    c. Medical Indemnity - $25,000

68. Reporting an Accident
    Any time you are involved in an accident, or have knowledge about a potential liability situation while performing assigned duties, you must notify your supervisor immediately.

    Any time you are involved in an accident, or have knowledge about a potential liability situation while performing assigned duties, you must notify your supervisor immediately.

70. Verification*

    Check the box and enter your name and the date to verify you have read and understood the above insurance limitations.

    1. I have read and understood the insurance limitations.
72. Volunteer's Signature*

73. Date*
    Date

    Date

Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field