Item #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
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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
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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
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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;
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Print Name PnntN e
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Date Date