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Home My WebLink AboutItem #03 Appointment to the Human Relations Diversity Boardocoee florido AGENDA ITEM COVER SHEET Meeting Date: April 21, 2015 Item # 3 Contact Name: Contact Number: Nichole DeRienzo Ext. 1024 Reviewed By: Department Director: Beth City Manager: Robert Fral Subject: Appointment to the Human Relations Diversity Board (3 -year term §) Background Summary: Members of the Human Relations Diversity Board serve three -year terms. Currently the Human Relations Diversity Board has ten (10) members and their resolution allows no less than seven (7) members and no more than thirteen (13) members. One (1) application has been submitted to serve on the board; Nathaniel Briggs has expressed his interest in serving on the board. Issue: Should the honorable Mayor and City Commission appoint Mr. Briggs to the Human Relations Diversity Board with a term ending May 2018? Recommendations Staff recommends that the City Commission consider appointing Mr. Briggs to the Human Relations Diversity Board with a term ending May 2018. Attachments: Board List Board Application Financial Impact: None. Type of Item: (please mark with an `Y) Public Hearing For Clerk's Dept Use: Ordinance First Reading X Consent Agenda Ordinance Second Reading Public Hearing Resolution Regular Agenda X Commission Approval Discussion & Direction Original Document/Contract Attached for Execution by City Clerk Original Document/Contract Held by Department for Execution Reviewed by City Attorney N/A Reviewed by Finance Dept. N/A Reviewed by () N/A HUMAN RELATIONS/DIVERSITY BOARD Created by Res. #2003 -21 on 9/16/2003 Res. #2003 -21 amended by Res. # 2004 -11 changing quorum to 50% plus (1) one; amended by 2010 -10 (residency for membership); amended by 2013 -07 changing terms to 3 years and membership to 13. No less than 7 members, no more than 13 members - (3 year terms) MEMBER DISTRICT CONTACT INFORMATION TERM ENDS 1. Billie Jean Daily 4 407 - 286 -2164 (C) May 2017 5037 Water Wheel Court 2 Barbara Anne Boudokhane 407 -591 -8033 (C) May 2017 42 South Park Avenue, Apt. 104 Bashibabingggmail.com Winter Garden, FL 34787 3. Ira Calloway n/a 407 - 295 -1418 (H) May 2017 1306 Weston Wood Blvd i.callowaygatt.net Orlando, FL 32818 4. Nichole Dawkins 4 407 - 860 -0639 (H) May 2017 1326 Plumgrass Circle 407- 296 -0002 (W) taiena5 e ,aol.com 5. Sandria Foster 1 407 - 296- 5263(H) May 2016 3343 Atmore Terrace Fosteres3(2yahoo.com 6. Sarah "Beth" Freeman n/a 407 - 656 -5572 (H) May 2016 535 Woodson Avenue 407 - 656 -4397 ext. 114 (W) 407 - 448 -0387 (C) bethf ,cortezinc.net 7. Jennifer Hopkins 2 407 - 293 -4159 (H) May 2016 2391 Alclobe Circle 407 - 375 -5041 (C) hopkinsjjgmsn.com 8. William Maxwell 2 407 - 656 -0054 (H) May 2016 558 Woodson Avenue 407- 447- 3117(W) 407- 694 -5905 (C) 407 - 447 -4746 (F) wemaxcom(2aol.com 9. Sujeily Ruiz 1 407 - 342 -3371 (C) May 2017 2005 Lauren Beth Ave. sujeily rzgyahoo.com 10. Pastor Gabriel Padilla 2 321 - 438 -0162 May 2017 120 W. McKey St. gabby_padilla84kyahoo.com Elevation Christian Church Ocoee, Fl. 34761 11. Page 1 of 2 12. 13. STAFF LIAISON Joy Wright City Manager 407 - 905 -3100 ext. 9 -1530 Community Relations Manager joy.wright cgci.ocoee.fl.us EX- OFFICIO MEMBER Joel Keller Commission 407 - 905 -3100 ext. 9 -1040 Commissioner 4 JKellergei.ocoee.fl.us RECORDING CLERK 407 - 656 -5572 (H) Beth Freeman 407 - 656 -4397 ext. 114 (W) 407 - 448 -0387 (C) bethfgcortezinc.net EXECUTIVE MANAGEMENT Al Butler, Director Support 407 - 905 -3100, ext. 9 -1543 Services AButlergci.ocoee.fl.us Doug Gaines, Assistant Director Support 407 - 905 -3100, ext. 9 -1503 Services d a� inesgocoee.org Page 2 of 2 florido APPLICATION FOR SERVING ON CITY BOARDS This Applicant Information Form, when completed and filed with the City Clerk's Office, is a PUBLIC RECORD under Chapter 119, Florida Statutes, and therefore, is open to public inspection by any persons. Name: (A ;AT Home Address: 6 t e Ai L c 1 b H D+2 City, State, Zip: Q C. o c t F L, 3 it - 2 j Business: NU M i L 1 TT L& L Business Address: i3Q 6 L eAlL ei 6H D9. Brief rr Summary of Qualifications and Experience:, L^ trr/M1.�tcr1 7CC(i/10 -1'nA ta3& E -mail Address: AlA t-IAN1 EL . YZ(b65Q 00TtcnIV. (o AA Home Phone: '-t a 7 - 4 � j - (o 1 �r $ Business Phone: i G r; J On CAn 1 n 5. Are you a U.S. citizen? Yes: No: L Are you a registered voter? Yes: C No: District #: 6. Resident of the City for 6 months or longer? Yes: No: 7. Do you hold public office? Yes: No: 8. Are you employed by the City? Yes: No: 9. Do you now serve on a City Board or Committee? Yes: No: 10. Please attach any information that would assist Commission in making appointments. Department (CACOPD) PLEASE CHECK THE BOARDS WHICH INTEREST YOU BY INDICATING YOUR FIRST AND SECOND CHOICE ( #1, #2). *FINANCIAL DISCLOSURE FORMS ARE REQUIRED FOLLOWING APPOINTMENT By my signature below, I attest that the information provided herein is true and correct and I acknowledge and agree that a background check may be required when duties include contact with children. SIGNATURE: ` ' 1 DATE: 2 Note: (1) Application effective ONE YEAR from date of completion. It can be faxed to (407) 905 -3168. (2) If you have any questions, please call the City Clerk's office at (407) 905 -3105. City of Ocoee - 150 N. Lakeshore Drive ■ Ocoee, Florida 34761 Phone: (407) 905 -3100 - Fax: (407) 905 -3168 ■ Website: www.ocoee.org *Code Enforcement Board 2— Human Relations Diversity Board *Board of Adjustment Parks & Recreation Advisory Board Community Grant Review Board Personnel Board Citizen Advisory Council of Fire 1 *Planning & Zoning Commission Department CACOFD Citizen Advisory Council of Police *Police Officers' and Firefighters' 3 Department (CACOPD) Retirement Trust Fund Board of Trustees *General Employees' Retirement OTHER: Trust Fund Board of Trustees *FINANCIAL DISCLOSURE FORMS ARE REQUIRED FOLLOWING APPOINTMENT By my signature below, I attest that the information provided herein is true and correct and I acknowledge and agree that a background check may be required when duties include contact with children. SIGNATURE: ` ' 1 DATE: 2 Note: (1) Application effective ONE YEAR from date of completion. It can be faxed to (407) 905 -3168. (2) If you have any questions, please call the City Clerk's office at (407) 905 -3105. City of Ocoee - 150 N. Lakeshore Drive ■ Ocoee, Florida 34761 Phone: (407) 905 -3100 - Fax: (407) 905 -3168 ■ Website: www.ocoee.org VOLUNTEER RELEASE — WAIVER FORM zo OCO( >P fle�lda Position Volunteering For: OwNw, , l %n I l Va Department to Volunteer: Full Name: � Vwis OA id S a I-E4 5 Other Names or SSN used: Current Address: t; l� ( I yA it i q9, A f 0 C C--*t F— 11 3 4 Street ` City State Zip Current Phone: `f o ) " if c� Driver's License # 6 (, Z0 O' W? Z 0 1 / 2 0 State F— U SSN# 7 DOB: Q L �L .`t /qZ Current Employer: 1 m / L ..T r L- t- 6- i f s Supervisor's Name: Current Employers Phone: Are there any criminal offenses for which you were convicted, plead guilty to or had adjudication withheld? Yes _" No. If yes, give dates and explain on the back of this form. A conviction will not necessarily disqualify yo u from volunteering. As an applicant for a volunteer position with the City of Ocoee, I am willing to furnish information for use in determining my qualifications. For this purpose, I authorize release of any and all information that may be available concerning me, including information of a confidential or privileged nature. I hereby release you, the City of Ocoee and others from liability or damage which may result from furnishing the information requested. I understand that for security reasons a background check may be conducted to determine my eligibility. I may also be required to supply my social security number, be finger printed or submit to a drug screening. Further background information will be requested only if a specific volunteer assignment calls for a full security check. As a volunteer for the City of Ocoee, I understand that I can be dismissed without cause and without notice, and that I am not eligible for compensation or benefits for services rendered. In consideration of the permission granted me by the City of Ocoee, to participate as a volunteer to and within the City and any and all activities or events related to this volunteer assignment, I the Undersigned for myself, my heirs, assigns and administrators, HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE THE CITY OF OCOEE AND ITS AGENTS, OFFICERS AND EMPLOYEES from all liability to the Undersigned, my heirs, assigns and administrators, of and from all claims and demands, actions and causes of action of any kind (inclusive of claims for personal injuries and property damage), damages, losses and liabilities, costs, expenses and unknown, foreseen and unforeseen damages and consequences thereof, caused by or arising out of my participation in any volunteer assignment. I certify and warrant that I am in good physical condition and am able to participate as a volunteer in the agreed upon volunteer assignment and any and all activities or events related to this volunteer assignment, and do agree to do so at my own risk. I expressly agree and acknowledge that my participation in any above referenced activity or event is as a volunteer and not as an employee of the City of Ocoee and that I understand and agree that I shall not accrue nor shall I be entitled to any City employee benefits, wages or other incidents of employment by virtue of this agreement. NOTE: Updated backgrounds will be done on an annual basis. VOLUNTEER RELEASE — WAIVER FORM (con't) An OCOPP I HAVE CAREFULLY READ THE FOREGOING RELEASE AND WAIVER KNOW THE CONTENTS THEREOF AND I HAVE SIGNED THIS RELEASE AND WAIVER AS MY OWN FREE ACT. This Release and Waiver contains the entire agreement between the Undersigned and the City of Ocoee and the terms of this Release and Waiver are contractual and not a mere recital. I expressly agree that this Release and Waiver is intended to be as broad and as inclusive as permitted by the laws of the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding continue in full force and effect. Applicants under age 18 MUST have their parent or guardian sign. Signature Parent/Guardian: 7 ✓( 1 1 2� --�" Date: J 5 NOTE: The Volunteer Release and Waiver will not be considered if this form is incomplete and/or not signed. In the event it is believed there is a discrepancy in the information received during the criminal background, fingerprinting will be required to verify the validity of the information received. CITY OF OCOEE SOCIAL SECURITY POLICY STATEMENT The City of Ocoee, in accordance with Section 119.071(5) of the Florida State Statutes, recognizes that an individual's social security number is a unique form of identification that can be utilized to obtain sensitive information regarding that particular individual. However, the City of Ocoee must collect social security numbers under certain circumstances in order for the City to be able to properly perform its duties and functions as a municipal corporation and order to ensure that such duties and functions are performed accurately and efficiently. Due to the sensitive nature of an individual's social security number the City of Ocoee provides the following statement regarding the City's collection of social security numbers: THE CITY OF OCOEE COLLECTS YOUR SOCIAL SECURITY NUMBER ONLY FOR THE FOLLOWING PURPOSES: IDENTIFICATION AND VERIFICATION OF EMPLOYMENT AND PAYROLL; ■ CREDIT WORTHINESS ■ BILLING AND PAYMENTS • DATA COLLECTION, RECONCILIATION, AND TRACKNG; ■ BENEFIT PROCESSING; ■ TAX REPORTING; • NEW UTILITY ACCOUNT APPLICATIONS; ■ BANK DRAFT AUTHORIZATIONS; • VENDOR REGISTRATION APPLICATIONS; • VOLUNTEER CONTRACTS FOR BACKGROUND CHECKS; ■ EMERGENCY TRANSPORT FOR BILLING AND INSURANCE; POLICE STATEMENTS AND ARRESTS FOR VERff ICATION OF IDENTITY ■ VOLUNTARY FINGERPRINTING ■ EMPLOYEE INSURANCE AND PENSION ISSUES ■ LOCAL BUSINESS TAX APPLICATIONS; AND ■ TRAINING CERTIFICATIONS/LICENSURE Each individual who provides a social security number to the City of Ocoee shall be provided with a copy of this statement. Additional copies of this Social Security Policy Statement may be obtained by at, City Clerk's Office, at 150 North Lakeshore Drive, Ocoee, FL 34761. My signature represents that I have read and understand the content of this document. Volunteer Signature Witn ss t Signat; s t n ;L ' rf Print Name PnntN e o , � ,zc�S 413 01f its Date Date