Free 38445.FH11 - Indiana

Reset Form

APPLICATION FOR CERTIFICATION AS A VOLUNTEER OUTDOOR EDUCATION INSTRUCTOR
State Form 38445 (R4 / 3-09)

DEPARTMENT OF NATURAL RESOURCES Law Enforcement Division Outdoor Education Section

INSTRUCTIONS:
Type of certification

Forward completed application to District Headquarters.
Education program applying for:

New

Recertification

Hunter Education

Boating Education APPLICANT INFORMATION

ORV Education

Trapper Education

NASP

Name of applicant (last, first, middle, previous or maiden name) Mailing address (number and street, city, state, and ZIP code) Home telephone number Other telephone number Age

Sex

Race

Male

Female

Date of birth (month, day, year)

County of residence

(

)

(

)
EDUCATIONAL BACKGROUND
FOR HQ USE ONLY - Printed name (last, first)

Please check the highest high school grade completed

Please check the highest college year completed

Years of post graduate work completed Post graduate degree / major

9

10

11

12

1

2

3

4

5

Other (trade, professional courses, certificates, etc.)

College degree / major

EXPERIENCE
Please indicate the approximate amount of time spent participating in each of the following activities:

Hunting ______ years

Archery ______ years

Trapping ______ years EMPLOYMENT

Boatling ______ years

ORV ______ years

Name of employer / organization Address (number and street, city, state, and ZIP code) Title of present or last job

Telephone number

(

)

PERSONAL REFERENCES
Name of reference (last, first, middle initial) Address (number and street, city, state, and ZIP code) Name of reference (last, first, middle initial) Address (number and street, city, state, and ZIP code) Name of reference (last, first, middle initial) Address (number and street, city, state, and ZIP code) Home telephone number Work telephone number Home telephone number Work telephone number Home telephone number Work telephone number

HQ instructor number

(

)

(

)

(

)

(

)

(

)

(

)

INSTRUCTOR CERTIFICATIONS

MEMBERSHIPS (CLUBS OR ORGANIZATIONS)

District number

Page 1 of 2

VOLUNTEER SERVICE AGREEMENT This agreement is entered with the Indiana Department of Natural Resources to govern volunteer services. It is mutually agreed that I will assist and work with the Department of Natural Resources, Law Enforcement Division, Outdoor Education Section. I further agree that I am a volunteer for the State of Indiana and I am a temporary employee and not for compensation. I understand that I will receive no payments or remuneration for my volunteer work and that I am exempt from minimum wage and maximum hour working provisions of the Fair Labor Standards Acts. I further understand that if I am injured while working for the State of Indiana as a volunteer, Workman's Compensation will be the sole and exclusive remedy for any such injury. NONDISCRIMINATION DISCLOSURE By the signature below I agree to the following equal opportunity provisions of the Outdoor Education Program: 1. No person, on the grounds of race, color, sex or national origin, will be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the program. 2. No qualified physically challenged person shall, on the basis of handicap; be excluded from participation in, be denied benefits of, or otherwise be subjected to discrimination under the program. 3. No person shall, on the basis of age, be excluded from participation as identified by state statutory objectives. In making this application for certification as a volunteer outdoor education instructor, I understand that as part of the Indiana Department of Natural Resources normal procedure, I will be investigated. A routine inquiry may be made where by information is obtained through personal interview with third parties, such as family members, business associates, friends, neighbors or others with whom I am acquainted. This inquiry can include information as to my character, general reputation, and any past police, sex offender, and Department of Natural Resources record which I may have.
Signature of applicant Date signed (month, day, year)

Questions 1 - 9: If the answer to any of the following questions is yes, explain fully on a separate sheet of paper and attach it to this application. 1. Do you currently have any charges pending in any court, or conviction in any court for any crime which is a felony or any Yes misdemeanor as described in the Indiana state law, or for any offense including driving while intoxicated (DWI), except traffic 2. infractions? Do you currently have charges pending in any court, or conviction in any court for any misdemeanor crime associated with domestic violence (includes any misdemeanor involving the use or attempted use of physical force committed by a current or former spouse, parent, or guardian of the victim by a person with a similar relationship with the victim)? Are you under a court order restraining you from harassing, stalking, or threatening an intimate partner or child or such partner? Have you ever been ticketed, charged, or arrested for a violation of a Fish & Wildlife, boating, or off road vehicle (ORV) law? Have you ever been adjudicated mentally defective or been committed to a mental institution? Have you been discharged from the Armed Forces of the United States under dishonorable conditions? Have you renounced your United States citizenship? Are you an unlawful user of, or addicted to, marijuana, any depressant, stimulant, or narcotic drug, or any controlled substance? Have you ever had a personal protection permit or any application for such a license disapproved or had such a license revoked or cancelled? FOR DEPARTMENT OF PERSONNEL USE ONLY RECOMMENDATION FOR APPROVAL

No

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

3. 4. 5. 6. 7. 8. 9.

The applicant has been contacted and the appropriate Outdoor Education Program has been fully explained. A sufficient number of persons have been contacted and indicate the applicant is of good character. The applicant, if trained, will be suitable as a volunteer instructor.
Police record Signature of officer Printed name Printed name Date signed (month, day, year) Date signed (month, day, year)

Yes / attached
DNR check

No
District command

Yes

No NON-APPROVAL OF APPLICANT

This applicant is not recommended for approval for the following reasons: (attach additional sheet if necessary)

Signature of officer District command Division approval District assigned number

Printed name Printed name Printed name

Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year)

HE: __________________

BE: __________________

ORV: __________________ Page 2 of 2

TE: __________________

NASP __________________