Volunteer Form F180 - Johnson County Library

Volunteer Form
F180
Full Name:
Last
First
M.I.
Address:
Street Address
City
State
Phone:
ZIP Code
Email Address:
Birth Date:
Emergency
Contact:
Name
Education:
Relationship
Less than High School
High School or GED
Four-Year College Degree
Advanced Degree
Phone
Some College
School Attending Now: (Students Only)
Retired:
Yes
No
Current/Most Recent Employer:
Job Title:
Days/Hours Available to Volunteer:
Preferred Library Location:
Skills/Abilities/Interests
Other Skills:
Computer
Board/Leadership
Foreign Language:
Teaching:
Previous Volunteer or Board Experience
Hobbies/Leisure Activities
(Adults) If accepted for volunteer service, I will attend required training and give service on a regular basis.
I agree to a one-year commitment.
(Students) If accepted for volunteer service, I will attend training and give service on a regular basis.
I agree to work a minimum of 50 hours.
Signature:
Date:
VOLUNTEER AGREEMENT TO MAINTAIN CONFIDENTIALITY
JOHNSON COUNTY LIBRARY
I understand and agree that all records of any kind pertaining to patrons of the Johnson
County Library, including but not limited to personal, registration, circulation and check-out,
financial, and library usage records, are confidential and protected from viewing and disclosure
pursuant to Johnson County Library Administrative Regulation Manual (ARM) section 20-2020, “Confidentiality of Records.” All such records are referred to in this Agreement as “Patron
Confidential Information.”
I agree that I will not view or use Patron Confidential Information except as authorized
by a library supervisor. I agree that I will view or use such information only for the purpose of
performing my duties at the Johnson County Library.
I further agree that I will not directly or indirectly disclose, publish, communicate or
divulge to third parties any Patron Confidential Information that I view or to which I have
access. Pursuant to ARM 20-20-20, I will immediately refer inquiries made by third parties
about Patron Confidential Information to a library supervisor.
I agree that if I have questions about whether certain information is Patron Confidential
Information, I will immediately contact my supervisor.
I understand and agree that if I view, use, or disclose Patron Confidential Information
in violation of this Agreement, I will be subject to immediate dismissal.
I have read the statements above and agree to be bound by this Agreement and
applicable sections of the Administrative Regulation Manual in performing services as a
volunteer of the Johnson County Library.
_________________________________________
Volunteer signature
Print name: _______________________________
Date: ____________________________________
Release to Use Photographs, Video, Audio, Name and Other Reproductions
I hereby grant to the Johnson County Library and its employees, legal representatives and assigns in
the performance of their duties for Johnson County Library, the absolute right and permission to
use or copyright, in its own name or otherwise, and re-use, broadcast or digitally transmit, publish,
and republish photographic pictures, video, electronic images or other reproductions of me or in
which I may be included, and audio recordings in which I speak or perform, in whole or in part,
without restriction as to changes or alterations, in conjunction with or without my own name in
color or otherwise, made through any medium, and in any and all media now or hereafter known for
illustration, promotion, art, advertising, trade, including film, photographic, video, audio, electronic
or digital formats or reproductions, or any other purpose whatsoever. I also consent to the use of
any printed or electronic matter in conjunction therewith. The uses and rights granted herein are
donated to Johnson County Library freely and without financial consideration as a public service.
To the extent that I have participated in a performance of any kind, which is defined herein to
include but not be limited to a reading or discussion of my writing, I waive any right to claim a
performance fee for the broadcast or rebroadcast of an audio or video recording of such
performance. I hereby waive any right that I may have to inspect or approve the finished product or
products and the advertising copy or other matter that may be used in connection therewith or the
use to which it may be applied.
I hereby release, discharge and agree to save harmless Johnson County Library, its employees,
departments, legal representatives and assigns, and all persons acting under this Release, from any
liability for such use, including by virtue of any blurring, distortion, alteration, optical illusion, or use
in composite form, whether intentional or otherwise, that may occur or be produced in such use or
in any subsequent processing thereof, as well as any publication thereof, including without limitation
any claims for libel or invasion of privacy.
I hereby warrant that I am of legal age and have the right to contract in my own name or I am the
parent or legal guardian of the subject for whom this Release is granted. I have read the above
Release, prior to its execution, and I am fully familiar with and understand the contents thereof.
This Release shall be binding upon me and my heirs, legal representatives, and assigns.
Date: _________________ Signature: _________________________________________
Print Name: _____________________________________________________________
Address: ________________________________________________________________
Name of other person for whom Release is given (if applicable): _____________________
Relationship of such person to signer: _________________________________________
This release affects your legal rights.
If not understood, please consult your own legal counsel.
For JCL Staff
Title & location of event:
Description of photograph(s) and other media associated with release (please use the back of page as
needed):