OMB 0596-0080 (Expires 12/2013)
Volunteer Services Agreement for Natural Resource Agencies
for Individuals or Groups
Please print when completing this form (Attach a sprarate sheet for those data that do not fit in the allowed spaces)
Site Name
Project Leader
Agency
Reimbursement (if sny)
Name of Volunteer or Group Leader
Last    First    Middle 
Age (If Individual Agreement)
 Under 18   18-25   26-55   56 and Over
Are you a U.S. Citizen?
 Yes   No  Visa Type
Email Address
Home Phone
Mobile Phone
Street Address
CityStateZip
   
IF VOLUNTEER IS UNDER AGE 18 - Name of Parent or Legal Guardian
Home PhoneMobile PhoneEmail
  
Street Address
CityStateZip
   
I affirm that I am the parent/guardian of the above named volunteer. I understand that the agency volunteer program does not provide compensation, except as otherwise provided by law; and that the service will not confer on the volunteer the status of a Federal employee. I have read the attached description of the service that the volunteer will perform. I give my permission for (volunteer name) to participate in the specified volunteer activity sponsored by (sponsoring organization) at (name of volunteer duty station)

From:  to     
  mm/dd/yyyy   mm/dd/yyyy    Parent/Guardian Signature mm/dd/yyyy
Emergency Contact Name
Home PhoneMobile PhoneEmail
  
Street Address
CityStateZip
   
GOVERNENT OFFICIAL COMPLETES THIS SECTION
Description of service to be performed. Include details such as time and schedule commitment, use of personal equipment, government vehicle, skills required (note certifications if necessary), level of physical activity required, etc. Attach the complete job description and job hazard analysis to this form. If this is a group agreement, the leader is to provide the group name, a complete list of group participants to be attached to this form, and parental approval (above) completed for each volunteer under the age of 18.

MOUNTAIN BIKE TRAIL BUILDING


Location: Meet at Trail Head Parking Lot located at: 10324 Belmont Blvd., Lorton, VA 22079
Dates for 2013: March 2, 16 and 30
April 13 and 27
May 11, 18 and 25
June 8, 22 and 29
July 13, 20 and 27
August 10, 17 and 24
Time: 9:00 a.m. to 3:00 p.m.


FOR MORE INFORMATION CONTACT and to RSVP:

Doug Vinson, Recreation Specialist, (804) 852-3370
Russ Adams, MORE Trail Liaison (703) 919-0878

Note: Fifteen to twenty volunteers are needed on Saturdays beginning March 2, 2013 and other dates posted above. Unfortunately we do need to put a cap on how many volunteers can join. A maximum of 20 volunteers will be allowed to participate.

This is a great opportunity for those of you who may need service learning hours (7 hrs) or who just want to help the BLM with this new trail. Anyone under the age of 18 must have a parent or legal guardian fill out the approval section of the Volunteer Agreement before volunteering. Prospective volunteers may pre-register by completing the application in advance. It would be helpful for you to bringing a printed copy with you when you arrive. Note: Youth volunteers will need to have the parental approval and photo release signed by a legal guardian.

The BLM staff has developed a Risk Analysis for this project that is available for review by participants who will be volunteering to assist with the various tasks. A Safety brief will be held for each task and appropriate protective gear will be provided to all volunteers.

SAFTEY is EVERYONE'S Responsibility!

Water and Snacks will be provided. Bring gloves if you have them.
Government Vehicle required?    Yes   No
Personal Vehicle to be used?    Yes   No
 Valid State Driver's License
 International Driver's License
Please verify that the volunteer is in possession of one of these documents. DO NOT keep a copy of the document for his/her file.
I understand that I will not receive any compensation for the above service and that volunteers are NOT considered Federal employees for any purpose other than tort claims and injury compensation. I understand that volunteer service is not creditable for leave accrual or any other employee benefits. I also understand that either the government or I may cancel this agreement at any time by notifying the other party.

I understand that my volunteer position may require a reference check, background investigation, and/or a criminal history inquiry in order for me to perform my duties.

I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my volunteer services as specifically stated in the attached job description, will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws.

I understand the health and physical condition requirements for doing the work as described in the job description and at the project location, and certify that the statement I have checked below is true:

I know of no medical condition or physical limitation that may adversely affect my ability to provide this service.
I do know of a medical condition or physical limitation that may adversely affect my ability to provide this service and have explained it to (Name of Agency Official).


I do hereby volunteer my services as described above, to assist in agency-authorized work. I agree to follow all applicable safety guidelines.

   
(Signature of Volunteer)(Date)


The above-named agency agrees, while this arrangement is in effect, to provide such materials, equipment, and facilities that are available and needed to perform the service described above, and to consider you as a Federal employee only for the purposes of tort claims and injury compensation to the extent not covered by your volunteer group, if any.

   
(Signature of Governmenet Representative)(Date)

Termination of Agreement

Volunteer requests formal evaluation  Yes   No    Evaluation Completed  (mm/dd/yyyy)

Agreement Terminated on:


(mm/dd/yyyy)


(Signature of Government Representative)

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596- 0080. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) and U.S. Department of the Interior (USDI) prohibit discrimination in all programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA and USDI are equal opportunity providers and employers.

Privacy Act Statement

Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA and USDI for the purposes of tort claims and injury compensation. Furnishing this data is voluntary, however if this form is incomplete, enrollment in the program cannot proceed.

Media Release

I give to the U.S. Bureau of Land Management (BLM) and National Environmental Education & Training Foundation (NEEF), its assigns, nominees and agents unlimited permission to use, publish, republish and share with media, partners and sponsors, information about me and video, photographic or digital images and reproductions of my likeness (photographic, video, or otherwise) and my voice, whether or not related to any affiliation with the National Environmental Education Foundation, with or without my name.

Minors (under the age of 18) who appear in submitted photographs must have a parent/legal guardian sign their release.

Signature of Volunteer Siganture Date



Optional Form 301a (09/2010)
USDA-USDI