Form PR9186 "Recreation Education Training Instructor Application" - Michigan

What Is Form PR9186?

This is a legal form that was released by the Michigan Department of Natural Resources - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 5, 2014;
  • The latest edition provided by the Michigan Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PR9186 by clicking the link below or browse more documents and templates provided by the Michigan Department of Natural Resources.

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Download Form PR9186 "Recreation Education Training Instructor Application" - Michigan

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Michigan Department of Natural Resources – Law Enforcement Division
DNR U
O
SE
NLY
R
E
T
I
A
ECREATION
DUCATION
RAINING
NSTRUCTOR
PPLICATION
By authority of 1994 PA 451, as amended, completion of this application is required, for consideration as an instructor
I
: Print or type name exactly as it appears on your driver’s license (must be 18 years of age or older to apply).
NSTRUCTIONS
A
I
PPLICANT
S
NFORMATION
Applicant's Name (Last, First, M.I.)
Last four digits of Social Security No.
Driver’s License Number
Street Address
County of Residence
Date of Birth
Sex/Race
City
State
ZIP
Occupation
Home Telephone
Business Telephone
E-Mail
(
)
(
)
Are you currently certified and adding another program to your certification?
If yes, instructor number:
I’m applying for certification in
Hunter Safety
Bow Hunter
Boating Safety
Snowmobile Safety
ORV
Trapper Ed
Attach a copy of your Student Certificate of Completion for the Instructor certification course in which you are applying. (required)
Do you have any disabilities? (this information is voluntary and will be used for statistical purposes only)
YES
NO
Provide teaching and/or special training experience. (attach copies of certificates)
Give two references of who may have knowledge of your qualifications to become an Instructor.
1. Name
Telephone (
)
Telephone (
)
2. Name
Are you currently joining a team or club that is teaching Recreation Safety?
YES
NO
If yes, list club or organization and point of contact.
Give a brief explanation of your interest to become a Recreation Education Instructor.
Have you ever been convicted?
of a Misdemeanor (including moving violation)
YES
NO
of a Felony
YES
NO
of a Conservation Violation
YES
NO
If certified a uniform vest is issued – (Hunter Education, Bow Hunter, Trapper and ORV only) V
S
EST
IZE
I hereby certify that the statements on this application are true. I understand certification can be denied by the Michigan
Department of Natural Resources (DNR) if information has been falsified or misleading. I authorize the Michigan DNR to
conduct a background investigation prior to certification.
Signature of Applicant
Date
**DNR U
O
** - B
I
SE
NLY
ACKGROUND
NVESTIGATION
Approved
Not Approved
Completed By:
Signature
Date
Printed Name
M
I
ENTOR
S
NFORMATION
I hereby certify that this applicant has helped teach at least one recreational safety training class (Required for Hunter, Bow
Hunter and Trapper Ed.) and has demonstrated the skills necessary to become an instructor.
MENTOR
Mentor’s Instructor No.
Printed Name
Signature
(must be signed before re-submitting)
COMPLETE REVERSE SIDE
Submit the completed application to:
For information or assistance:
LAW ENFORCEMENT DIVISION – RECREATION EDUCATION PROGRAM
Telephone: (517) 284-6055
MICHIGAN DEPARTMENT OF NATURAL RESOURCES
PO BOX 30031
LANSING MI 48909
PR9186 (Rev. 08/05/2014)
Michigan Department of Natural Resources – Law Enforcement Division
DNR U
O
SE
NLY
R
E
T
I
A
ECREATION
DUCATION
RAINING
NSTRUCTOR
PPLICATION
By authority of 1994 PA 451, as amended, completion of this application is required, for consideration as an instructor
I
: Print or type name exactly as it appears on your driver’s license (must be 18 years of age or older to apply).
NSTRUCTIONS
A
I
PPLICANT
S
NFORMATION
Applicant's Name (Last, First, M.I.)
Last four digits of Social Security No.
Driver’s License Number
Street Address
County of Residence
Date of Birth
Sex/Race
City
State
ZIP
Occupation
Home Telephone
Business Telephone
E-Mail
(
)
(
)
Are you currently certified and adding another program to your certification?
If yes, instructor number:
I’m applying for certification in
Hunter Safety
Bow Hunter
Boating Safety
Snowmobile Safety
ORV
Trapper Ed
Attach a copy of your Student Certificate of Completion for the Instructor certification course in which you are applying. (required)
Do you have any disabilities? (this information is voluntary and will be used for statistical purposes only)
YES
NO
Provide teaching and/or special training experience. (attach copies of certificates)
Give two references of who may have knowledge of your qualifications to become an Instructor.
1. Name
Telephone (
)
Telephone (
)
2. Name
Are you currently joining a team or club that is teaching Recreation Safety?
YES
NO
If yes, list club or organization and point of contact.
Give a brief explanation of your interest to become a Recreation Education Instructor.
Have you ever been convicted?
of a Misdemeanor (including moving violation)
YES
NO
of a Felony
YES
NO
of a Conservation Violation
YES
NO
If certified a uniform vest is issued – (Hunter Education, Bow Hunter, Trapper and ORV only) V
S
EST
IZE
I hereby certify that the statements on this application are true. I understand certification can be denied by the Michigan
Department of Natural Resources (DNR) if information has been falsified or misleading. I authorize the Michigan DNR to
conduct a background investigation prior to certification.
Signature of Applicant
Date
**DNR U
O
** - B
I
SE
NLY
ACKGROUND
NVESTIGATION
Approved
Not Approved
Completed By:
Signature
Date
Printed Name
M
I
ENTOR
S
NFORMATION
I hereby certify that this applicant has helped teach at least one recreational safety training class (Required for Hunter, Bow
Hunter and Trapper Ed.) and has demonstrated the skills necessary to become an instructor.
MENTOR
Mentor’s Instructor No.
Printed Name
Signature
(must be signed before re-submitting)
COMPLETE REVERSE SIDE
Submit the completed application to:
For information or assistance:
LAW ENFORCEMENT DIVISION – RECREATION EDUCATION PROGRAM
Telephone: (517) 284-6055
MICHIGAN DEPARTMENT OF NATURAL RESOURCES
PO BOX 30031
LANSING MI 48909
PR9186 (Rev. 08/05/2014)
Michigan Department of Natural Resources – Human Resources
V
R
W
L
OLUNTEER
ELEASE AND
AIVER OF
IABILITY
Required by authority of the Michigan Department of Natural Resources, for volunteer assignment consideration.
Please read carefully! This is a legal document that affects your legal rights!
The State of Michigan, as an Equal Opportunity Institution, complies with federal and state laws prohibiting discrimination and harassment, including Title IV
and Title VII (with amendments) of the 1964 Civil Rights Act, Title IX of the Educational Amendment of 1972, Section 504 of the Rehabilitation Act of 1973,
Veterans Readjustment Act of 1974 as amended 38 USC 20-12 and the Americans With Disabilities Act of 1990. It is the policy of the State that no person,
on the basis of race, sex, height, weight, color, religion, national origin or ancestry, age, marital status, disability or veteran status, shall be discriminated
against in educational programs, activities, and employment.
The Michigan Department of Natural Resources (DNR) encourages and supports volunteers. As a volunteer, I have an
important role in providing services and programs to the public.
I want to work as a volunteer for the Michigan DNR which appoints people like me to serve and to help the Michigan DNR.
While I am serving as a volunteer, I have the same immunity from civil liability under Michigan law as an employee of the
Michigan DNR. After becoming a volunteer, the Michigan DNR will provide me with support, supervision, training, and supplies
for me to accomplish my assigned tasks.
Therefore, I do freely, voluntarily, and without duress, execute this Release and acknowledge the following terms:
1. Waiver and Release. I hereby release, waive, discharge and covenant not to sue the State of Michigan, its departments,
officers, employees and agents, from any and all liability to me, for all losses, injury, death or damage, and any claims or
demands thereto, on account of injury to person or property, or resulting in my death in reference to the activities
authorized in my work as a volunteer. I hereby covenant and agree to indemnify and save harmless, the State of Michigan,
its departments, officers, employees and agents, from any and all claims and demands, for all loss, injury, death or
damage, that any person or entity may have or make, in any manner, arising out of any occurrence related to the activities
authorized in my work as a volunteer.
2. Medical treatment. I release and discharge Michigan DNR from any claim that arises or may arise due to any first aid,
medical treatment, or service rendered to me. I understand that I may not be entitled to workers’ compensation.
3. Assumption of risk. I understand that my work for the Michigan DNR may include activities that may be hazardous. I
assume the risk of injury or harm in those activities I choose to do and release the Michigan DNR from all liability for injury,
illness, death, or property damage occurring from my work for the Michigan DNR.
4. Insurance. The Michigan DNR does not have responsibility for providing any health, medical or disability insurance
coverage for me. IT IS MY RESPONSIBILITY AS A VOLUNTEER TO ENSURE I HAVE MEDICAL/HEALTH INSURANCE.
As with other members of the public, I may file a claim with the State Administrative Board for personal losses that are
under $1,000.
5. Photographic release. I grant to Michigan DNR the right to use photographic images and video or audio recordings of me
that are made by Michigan DNR or others during my work assignment for Michigan DNR, including royalties, proceeds or
other benefits from use of the photographs or recordings.
6. Copyright laws. I understand that showing videos in public that are intended for home viewing is prohibited under the
U.S. copyright laws.
7. Background check. I understand that a criminal history check may be obtained prior to my appointment as a volunteer. My
signature below certifies that I agree to a criminal history check and agree to provide Michigan DNR with my date of birth.
8. Discrimination laws. I agree to follow Michigan DNR’s policy, along with state and federal laws that forbid discrimination
in employment, education, housing, public accommodation, law enforcement or public service based on a person’s religion,
race, color, national origin, age, sex, marital status, height, weight, or disability.
9. In-kind service. The Michigan DNR is eligible for some grants that require that the grant dollars received be matched by
the Michigan DNR. Many grants allow the use of in-kind services as a portion of this match in lieu of actual dollars. My
signature certifies that I consent to the use of my volunteer time as a possible in-kind match for grants received by the
Michigan DNR.
10. Other. I agree that this Release is intended to be as broad and inclusive as permitted by the laws of Michigan and that this
Release is governed by and will be interpreted according to the laws of Michigan. I understand that should any part of this
Release be ruled invalid by a court, the other parts will remain valid and continue to be in effect.
V
G
/O
D
(
)V
OLUNTEER
ROUP
RGANIZATION
ATE
S
OLUNTEERING
N/A
Name (please print)
Group/Organization Name
From
N/A
Signature
Signature of Parent/Guardian or Group Leader
To
Date of Birth
PR9186 (Rev. 08/05/2014)
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