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HomeMy WebLinkAboutCOPS Application ADA CompliantCity of Palm Desert Citizens on Patrol Volunteer Application Packet Skip to main content Accessible HTML packet rebuilt from the City of Palm Desert COPS application PDF for public-facing government use. City of Palm Desert Citizens on Patrol Volunteer Application Packet This document rebuilds the full application packet in accessible HTML. It preserves the source packet content while omitting handwritten example entries that appeared in scanned sample materials. Use this version for review, completion, printing, and public-facing publication. Important: This packet includes City of Palm Desert forms, Riverside County Sheriff’s Department forms, Riverside County RSVP forms, a California DMV driver record release form, and a Volunteer Disaster Service Worker registration form. Read each section carefully before completing and signing. Packet Overview Application packet contents Section Form or document Purpose 1 Citizens on Patrol Volunteer Application Applicant information, background, and volunteer commitment. 2 Medical Clearance Form Physician review of any restrictions or limitations. 3 Notice of Confidentiality, Acknowledgment Waiver, and No Feedback Waiver Required acknowledgments for confidential information and background review. 4 Ride-Along Application and Waiver Authorization and release related to ride-along participation. 5 RSVP Volunteer Application and Ethics Statement Volunteer enrollment, interests, and ethics/confidentiality statement. 6 Employer Pull Notice Program Authorization Authorization for release of driver record information. 7 Volunteer Disaster Service Worker Registration Form Registration and loyalty oath information. Citizens on Patrol Volunteer Application General Information Name Phone Present address City State ZIP Email address Employment from Employment to Driver’s license Please attach a copy of driver’s license. State Expiration date Social Security number (optional) Date of birth Height Weight Hair Eyes Sex Blood type Allergies Medications Physical limitations Criminal history Have you been convicted of a crime in the past ten years? (excluding misdemeanors and summary offenses) No, I have not been convicted of a crime in the past ten years Yes, I have been convicted of a crime in the past ten years If yes, please describe in full Please list any other credentials or skills such as business skills, CP, computer, etc. Languages spoken Please indicate the number of hours per week that you can volunteer for the COPS program Emergency Contact Information Name Relationship Phone Biographical Sketch Please include any pertinent information such as civic involvement, education, work experience, government agency clearances, and any other supplemental material relevant to serving as a COPS volunteer. Biographical sketch Please list below any aliases or other names used Related Experience and Certification Please attach a current resume of your work and educational history beginning with the completion of high school. Applicant certification: “I certify that the statements made by me on this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I agree that I will volunteer a minimum of twenty (20) hours per month unless granted a leave of absence.” Signature of applicant Date Recommended by Please return application to: City of Palm Desert Attn: COPS Program 45480 Portola Avenue Palm Desert, CA 92260 Medical Clearance Form Dear Physician: Applicant name wishes to participate in the Citizens on Patrol (COPS) Program to serve as an Ambassador for the City of Palm Desert. Please provide any information that may limit or prohibit this applicant from volunteering in the COPS Program. This completed form should be returned to your patient with any recommendations or restrictions that are appropriate. Recommendations, restrictions, or limitations Physician’s signature Date Physician’s name (printed) Physician’s address and phone number Thank you for your assistance. If you have any questions regarding this program, please call our recruiting officer at tel:7608629848(760) 862-9848. Notice of Confidentiality of City/Police Department Information Volunteers shall not disclose or allow access to information contained in or obtained from Local Summary Criminal History Information, records maintained by State Department of Justice, or material, documents and information received from the Federal Bureau of Investigation or any other agency of State or Federal government, unless such disclose or access is authorized by law. Volunteers shall not use any information derived from any City or Police Department sources or records for personal gain or use, except as authorized by law or City or Police Department policies and procedures. Volunteers shall not permit any person to receive information connected with the operation of the City of Police Department without permission of the respective agency or as otherwise provided by law or City or Police Department policies and procedures. Volunteers shall not disclose to anyone the fact to the nature of any investigation, except as provided by law or City or Police Department policies and procedures. Volunteers shall not give any unauthorized person any information concerning the location of records, weapons, ammunition, the number of officers on duty, shift assignment or patrol beat area. Serving the public provides each of us with great responsibility. Consequently, there can be no compromise in the requirement for all volunteers to follow the City and Police Department policies and procedures on records and information and this “Notice of Confidentiality of City/Police Department Information”. Any violation of said subject by a volunteer may result in severe disciplinary action and/or termination. Penal Code, Section 11142 relating to State Summary Criminal History information provides as follows: Any person authorized by law to receive a record or information obtained from a record who knowingly furnishes the record or information to a person who is not authorized by law to receive the record or information is guilty of a misdemeanor. Penal Code, Section 13302 relating to Local Summary Criminal History Information provides as follows: Any person of the local criminal justice agency who knowingly furnishes a record or information obtained from a record to a person who is not authorized by law to receive the record or information is guilty of a misdemeanor. I have read and understand the “Notice of Confidentiality of City/Police Department Information.” Printed name Signature Date Palm Desert Citizens on Patrol, 45480 Portola Avenue, Palm Desert, California 92260, tel:7608629848(760) 862-9848, https://www.cityofpalmdesert.org/City of Palm Desert website. Acknowledgment Waiver Name Address You will undergo a rigorous, in-depth background investigation as a result of your application for a volunteer position with the City of Palm Desert. In the event that your background investigation should uncover information that leads to a belief that you have or are engaged in illegal activities, we will notify the appropriate law enforcement agency for their continued investigation and possible prosecution. I have read the above notice and understand that any information concerning criminal activity that I have participated in is NOT protected by any form or confidentiality, regardless of where the information came from. I understand that any information discovered about me during the background process, may be used against me in further criminal investigation and prosecution. Applicant initials Failure to notify the City of Palm Desert of any changes during the background investigation can be grounds to deny your application. In addition, unreported law enforcement contacts will be cause for immediate disqualification. Signature Date No Feedback Waiver Name Address I understand that the background investigation performed as an applicant for the Palm Desert Citizens on Patrol (COPS) Program is for security purposes only. It is to assess qualifications for this specific position and is in no way to be construed as intended for any other purposes. I understand that I will be given NO FEEDBACK or results other than being notified of “passing” or “not passing”. Also, I acknowledge that these records are confidential and will be the property of the Palm Desert Police Department and will not be made available to any other law enforcement agency or employer without a Personal Information Waiver signed by me. Membership Denial Also, if I am not recommended to become a COPS volunteer, I understand that I will be given NO FEEDBACK as this means only that I do not meet the standards established for the COPS Program. Signature Date Riverside County Sheriff’s Department Ride-Along Application Riverside County Sheriff’s Department. Chad Bianco, Sheriff. Ride-along applicant information Applicant information field Entry Applicant information field Entry Applicant’s full name Date of birth Sex Ride-along applicant male Ride-along applicant female Date of application Date and time of participation Applicant’s complete address Phone number Applicant’s occupation (if student, name of school) Education level Driver’s license number State of issuance Next of kin to be contacted in case of emergency Telephone number Alternative contact number or email address Doctor or medical facility (name and address) Type of personal accident insurance Ride-along screening questions Question 1 Have you ever been arrested for a criminal offense other than minor traffic offenses? No, I have not been arrested for a criminal offense other than minor traffic offenses Yes, I have been arrested for a criminal offense other than minor traffic offenses If yes, please explain Question 2 Have you had any contact with the criminal justice system? No, I have not had contact with the criminal justice system Yes, I have had contact with the criminal justice system If yes, please explain Question 3. What are your reasons for requesting participation at this time? Approval for ride-along or direct law enforcement experience Approval status Selection Details Approved Ride-along application approved Reason for disapproval Disapproved Ride-along application disapproved Station Commander signature Watch Commander signature To Be Completed by Employee Assigned Assigned to Describe any significant crimes or problems you and your observer became involved in Number of hours observer remained Did observer interfere with your duties? No, observer did not interfere with duties Yes, observer interfered with duties If yes, explain Employee signature Agreement Assuming Risk of Death, Injury or Damage Waiver and Release of Claims As used in this agreement, the term “law enforcement department” shall include the Sheriff’s Department of Riverside County and the Police Departments of the cities within Riverside County. The term “county” shall refer to Riverside County and the term “city” shall refer to every city within Riverside County as appropriate. I have read and initialed the section defining “law enforcement department,” “county,” and “city.” I understand that, as a non-member and non-employee, I voluntarily requested permission to ride as a guest or observer in a law enforcement vehicle and to accompany members during the active performance of official duties. I also understand that I must not interfere with any law enforcement duty unless requested to do so in an emergency, and that audio or video recording of any portion of the ride-along is strictly prohibited without express permission from the Department. I understand that the work and activities of the law enforcement department are inherently dangerous and involve possible risk of death, injury, damage, expense, or loss to person and property, and that the department did not take the initiative in extending an invitation to ride or accompany its members. I understand that sworn employees of another agency, from this state or another, must be in possession of full peace-officer powers to participate in a ride-along; that the undersigned rides in an off-duty capacity; that no law enforcement is to be conducted by the undersigned; and that no concealed weapon will be displayed unless it is during a life-threatening emergency for the protection of human life or the prevention of bodily injury. I agree that the city, the county, the law enforcement department, any member of a law enforcement department, and the driver or owner of any automobile owned, operated by, or in the service of the city or county, together with their sureties, shall not be held liable or responsible under any circumstances for any injury, damage, expense, or loss to person or property incurred while riding as a guest or observer or while accompanying a member of the department during the active performance of official duties as a peace officer. Read and initial each section in this document before signing below. Applicant signature Date Applicant name printed Parent signature if applicant is a minor Parent signature date Parent name printed Address Phone After the ride-along, please use the space below to tell us about your experience and opinions RSVP Volunteer Application RSVP, 78900 Avenue 47, Suite 200, La Quinta, CA 92253. Phone tel:7607710501(760) 771-0501. Fax (760) 771-6267. Volunteers serving the Coachella Valley. Confidential Information Volunteer site Supervisor district number RSVP volunteer contact information Information field Entry Information field Entry Name - last Name - first Name - middle Address City State ZIP code Phone Email address Date of birth RSVP gender RSVP applicant male RSVP applicant female Disclaimer Riverside County Ordinance 440, as amended, states in Section 10.1F County Insurance: Such liability insurance as the State of California may carry shall be excess insurance over any other valid collectible insurance, including that provided by the volunteer worker. Volunteer workers are not covered by Workers Compensation Insurance or by County self-insurance for injury or accident arising out of volunteer service. I have read and understand the foregoing notice. In addition, I understand that as a volunteer for RSVP and the Riverside County Office on Aging I will not accept gifts or services from those I serve as a result of the performance of my duties as a volunteer. I further understand all information I obtain from those I serve is of a confidential nature and is not to be divulged outside the confines of the Agency. As well, I understand the RSVP and the Office on Aging has the right to accept my services as a volunteer or to revoke them at any time. Volunteer’s signature Date Emergency Contact Emergency contact Phone number Relationship Address City State ZIP code Supplemental Insurance Beneficiary Supplemental insurance beneficiary Phone number Relationship Address City State ZIP code Ethnicity Ethnicity: Asian-Pacific Islander Ethnicity: American Indian/Alaskan Native Ethnicity: Black/African American Ethnicity: Caucasian Ethnicity: Hispanic Ethnicity: Other If other, specify Languages spoken (check all which apply) Italian Japanese Korean Chinese French German Hebrew Thai Vietnamese American Sign Language Russian Native American dialect Spanish Other language If other, specify language Education (check the highest level completed) Education: Less than high school Education: High school diploma Education: Some college Education: College degree Education: Technical or trade school Education: Graduate school Occupation or profession Skills and interests (please check all which apply) Accounting or bookkeeping Administration, management, or personnel Advocacy Advisory council development Animal care Arts and crafts instruction Computer skills Construction Driving Food preparation Food programs Fundraising Host or hostess Insurance (health) Legal or law enforcement Legislation or policy change Medical or health aide Office or clerical Phone support Planning and needs assessment Reading to others Senior care Service contracts oversight Serving special needs people Social service or counseling Special events Tax preparation Teaching Visitor services Release of Information and Pictures As a volunteer for RSVP, I hereby authorize the Riverside County Office on Aging, RSVP Volunteer Program to disclose pictures taken of me, information and or statements I have given through interviews with staff, in press releases, articles, newsletters or advertisements. Volunteer’s signature Date Vehicle Insurance Information The following applies only to applicants whose volunteer service requires the use of their personal vehicle in the performance of the volunteer assignment. Driver’s license number State Limitations on license Automobile insurance carrier I hereby certify that I now maintain the minimum liability insurance coverage, as required by the State of California. I further certify that I will continue to maintain this coverage for as long as I am a volunteer with the County of Riverside and drive my private vehicle or a County vehicle on official County business. I further certify that I now have and will continue to maintain a current Driver’s License issued by the State of California. I also certify that I have no medical conditions precluding me from safely operating a vehicle. Volunteer’s signature Date Volunteer Statement of Ethics and Confidentiality I agree, as a volunteer, to conduct myself in accordance with the general and specific principles below: A. Ethics Volunteer/Customer Relationships I will maintain the confidentiality of all persons served. The nature of the work of the Agency or Department can be highly personal. It is paramount that I maintain the highest ethical standards. Acceptance of Gifts As a Volunteer, I shall not accept any gift, bonus, gratuity, favor, or loan from any customer of the Agency or Department. Appropriate Conduct I will refrain from participating in any activity in which my personal conduct is likely to result in inferior services, violations of the law, or behaviors, which would reflect negatively on the Agency or Department. Drugs/Alcohol I will refrain from the use of alcohol or other mood-altering drugs while in the performance of my duties as a Volunteer. B. Confidentiality I understand and fully acknowledge the high degree of importance of exercising discretion and confidentiality regarding all information to which I am exposed as a result of being affiliated with the Riverside County Office on Aging. I also recognize that I may have access to Agency personnel information, computer software and related documentation, financial records, minutes of meetings, methods of operation, and other information, which constitutes or contains confidential or proprietary information. I am also fully aware that I cannot share or discuss with anyone such confidential or proprietary information unless specifically asked to do so by my supervisor, either during the period I volunteer or for any time after I no longer am a volunteer with the RSVP Volunteer Program. C. Conditions of Limited Confidentiality There are certain specified conditions under which confidentiality is limited in order to protect the health and safety of others or myself. The specific conditions are: Where there is known or suspected elder abuse. Where there is known or suspected child abuse. Where there are threats of violence or harm to someone. Where there are threats of suicide. Where there is a threat to public safety. Signature of volunteer Date Employer Pull Notice Program Authorization for Release of Driver Record Information California Department of Motor Vehicles, a Public Service Agency. Employee name California driver license number Employer or company name I hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving record, to my employer. I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report at least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, driver’s license suspension, revocation, or any other action is taken against my driving privilege during my employment. I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code (CVC) Section 1808.1(k). I understand that enrollment in the EPN program is an effort to promote driver safety, and that my driver license report will be released to my employer to determine my eligibility as a licensed driver for my employment. Employee authorization Executed at city County State Date Signature of employee Authorized representative Company name I do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of this company, that the information entered on this document is true and correct, to the best of my knowledge and that I am requesting driver record information on the above individual to verify the information as provided by said individual. This record is to be used by this employer in the normal course of business and as a legitimate business need to verify information relating to a driving position not mandated pursuant to CVC Section 1808.1. The information received will not be used for any unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury (Penal Code Section 118) and false representation (CVC Section 1808.45). These are punishable by a fine not exceeding five thousand dollars ($5,000) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment. I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to CVC Sections 1808.45 and 1808.46. Authorized representative certification Executed at city County State Date Signature and title of authorized representative To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program you must submit the applicable forms: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at the https://www.dmv.ca.gov/portal/vehicle-industry-services/employer-pull-notice-program/California DMV Employer Pull Notice Program webpage or by calling tel:9166576346916-657-6346. Retention instruction: This form must be completed and retained at the employer’s principal place of business and made available upon request to DMV staff. Submission instruction: Do not return this form to DMV. Sheriff’s Department Volunteer Disaster Service Worker Registration Form Loyalty Oath under Code of Civil Procedure §2015.5 and Title 19, Div. 2, Chap. 2, Sub-Chap. 3, 2573.1. Highlighted areas required by regulation. Volunteer Disaster Service Worker registration information Information field Entry Information field Entry Last name First name Middle SSN Address City State ZIP County Home phone Work phone Cell phone Email Date of birth Driver license number Driver license classification Driver license expiration Professional license number or numbers FCC license (if applicable) FCC license expiration In case of emergency, contact Sex Age Height Weight Hair color Eye color Government Code §§3108-3109 Every person who, while taking and subscribing to the oath or affirmation required by this chapter states as true any material matter which he knows to be false, is guilty of perjury, and is punishable by imprisonment in the state prison not less than one nor more than 14 years. Every person having taken and subscribed to the oath or affirmation required by this chapter, who, while in the employ of, or service with, the state or any county, city, city and county, state agency, public district, or disaster council or emergency organization advocates or becomes a member of any party or organization, political or otherwise, that advocates the overthrow of the government of the United States by force or violence or other unlawful means, is guilty of a felony and is punishable by imprisonment in the state prison. Loyalty Oath or Affirmation (Government Code §3102) I, Print name do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservations or purpose of evasion; that I will well and faithfully discharge the duties upon which I am about to enter. I certify under penalty of perjury that the foregoing is true and correct. Loyalty oath signatures Date Signature If under 18 years old, signature of parent or guardian Signature of official authorized to administer loyalty oath Title This Block to Be Completed Only by Riverside County Sheriff’s Department Agency completion block Field Entry Field Entry Registered by Phone DSW classification Category Station DSW identification card issued DSW identification card issued: No DSW identification card issued: Yes Identification card ID number Registration date Expiration date Miscellaneous information Revised 10/07/2003. A maximum of 5 years from the date of the Loyalty Oath is given. Print Download HTML Document Notes This HTML version is intended to provide a logical reading order, accessible headings, labeled form controls, accessible tables, keyboard operability, and print-ready formatting. Action buttons are intentionally hidden during printing. For official publication, review contact information and routing instructions before posting. blob link.href