Form MRP 126A MRP 126A STUDENT VOLUNTEER SERVICE AGREEMENT

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 0579-0477. The time required to complete this
information collection is estimated to average 0.5 hours 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.

OMB Approved
0579-0477
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STUDENT VOLUNTEER SERVICE
AGREEMENT

UNITED STATES DEPARTMENT OF AGRICULTURE
MARKETING AND REGULATORY PROGRAMS

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 The Privacy Act of 1974, 5 U.S.C 552a, which
authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA 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.
NON-DISCRIMINATION STATEMENT:
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual
orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any
program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who
require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's
TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in
languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program
Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint
form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence
Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].
USDA is an equal opportunity provider, employer, and lender.
This agreement addresses the acceptance of volunteer service under, 5 Code of Federal Regulations Part 308, and Title 5, U.S. Code Section 3111. It also serves as a record of such service.

SECTION I – PERSONAL DATA
NAME (Print Last, First, Middle)

HOME PHONE NUMBER

ADDRESS (Include City, State, and ZIP Code)

MOBILE PHONE NUMBER
EMAIL ADDRESS

EDUCATIONAL INSTITUTION (Name and Address)

ACADEMIC DISCIPLINE

ACADEMIC LEVEL

CITIZENSHIP OR IMMIGRATION STATUS
Complete one of the following to attest to your citizenship or immigration status.

□ United States citizen
national of the United States
□ Noncitizen
An individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children
of noncitizen nationals born abroad.

resident
□ A lawfulAnpermanent
individual who is not a U.S. citizen who resides in the United States under legally recognized and lawfully recorded permanent
residence as an immigrant.

to work
□ An alienAnauthorized
individual who is not a citizen or national of the United States, or a lawful permanent resident, but is authorized to work in the
United States.

Enter the date that your employment authorization expires__________________________________.
Aliens authorized to work must enter one of the following to complete this section:
1. Alien Registration Number (A-Number)/USCIS Number _____________________________________.
2. Form I-94 Admission Number__________________________________________________________.
3. Foreign Passport Number and the Country of Issuance______________________________________.
MRP FORM 126A
AUG 2023

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STUDENT VOLUNTEER SERVICE AGREEMENT
SECTION II – Assignment Data to Be Completed by Federal Employee Supervisory Program Official
PROGRAM NAME

LOCATION

PROGRAM OFFICIAL’S NAME (Last and First)

SUPERVISORY PROGRAM OFFICIAL’S TITLE

PHONE NUMBER

EMAIL ADDRESS

BEGINNING DATE

LENGTH OF VOLUNTEER ASSIGNMENT
END DATE

HOURS/WEEK

DESCRIPTION OF SERVICE
Please define the role and services requested of the volunteer. Provide details describing duties, tasks and responsibilities, location of project/duties,
licensure, and/or certification if required, level of physical activity required, training if required, tools, equipment, and PPE needed and provided, supplies,
materials, etc. Include information regarding equipment and/or property that will be provided by the volunteer, if applicable. Attach additional sheets as
necessary. Please ensure that all attachments contain the name of the volunteer. Classified position descriptions will not be accepted.

Check all that apply, verify and initial, as required before submitting the agreement to the Volunteer Service Program Coordinator:

□ Uniform (if required); Initials of supervisor____________
□ Valid Driver’s License Verified (if required); Initials of supervisor____________
□ Valid Licensure/Certification Verified (if required); Initials of supervisor____________
Employment certificates or work permits as required by state or local authorities for volunteers under the
□ age
of 18 Verified (if applicable); Initials of supervisor____________
CERTIFICATION TO BE COMPLETED BY FEDERAL EMPLOYEE SUPERVISORY PROGRAM OFFICIAL
I certify the volunteer service is in accordance with appropriate Federal, State, and local regulations, regarding employment of minors.
The student volunteer will be supervised and provided materials, equipment, training, and use of facilities that are available and needed to perform the
volunteer service described above. A record of attendance and a written evaluation of the student's performance will be prepared for the student and the
educational institution at the end of this assignment.
I certify that the volunteer services to be performed by the student, as outlined in this Volunteer Service Agreement, will not displace any employee.
SIGNATURE OF FEDERAL EMPLOYEE SUPERVISORY PROGRAM OFFICIAL

MRP FORM 126A
AUG 2023

DATE

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STUDENT VOLUNTEER SERVICE AGREEMENT
SECTION III – STUDENT VOLUNTEER AGREEMENT
I understand that:


I will not receive pay for services rendered.



I am permitted access to the work site only during my approved duty hours.



I am not considered a Federal employee for any purpose other than for purposes of the Federal Tort Claims provisions published
in 28 U.S.C. 2671 through 2680, and U.S.C., Chapter 81, relative to compensation for injuries sustained during the performance
of work assignments.



I am not eligible for health insurance, life insurance, retirement, or any other benefits.



If the Federal Government later employs me, my volunteer service will not be credited for civil service retirement purposes.
However, the experience I gain may be credited to meet qualification requirements for employment.



My volunteer assignment may require a reference check, background investigation, and/or criminal history inquiry in order to
perform my assignment.



I am to conduct myself with honesty and integrity in the performance of my assignment and follow the rules of conduct of MRP,
the Department of Agriculture, and the Federal Government.



I am to safeguard Government business, which is not for public information.



I am not authorized to represent the agency in any matter or proceeding, nor expend government funds. Any inventions made
during the assignment must be submitted to the agency for a determination of rights. Prior approval must be obtained prior to
publishing the results of any work, study, or research.



My supervisor must give permission before I operate any government equipment, or handle any property, that said equipment or
property may be used for approved, official purposes only, and that I may be held responsible for any unreasonable damage.



I serve under the supervision of a Federal official and I, or the Department of Agriculture, Marketing and Regulatory Programs
may terminate my services and this agreement at any time.



A record of my attendance and an evaluation of my performance will be provided to my educational institution and me when my
work assignment is completed.

I agree to the conditions of my service as described above, to assist in authorized activities and to follow all applicable safety guidelines.
SIGNATURE OF VOLUNTEER

DATE

SECTION IV – EDUCATIONAL INSTITUTION AGREEMENT
NAME (Print Last and First)

TITLE

ADDRESS (Include City, State, and ZIP Code)

PHONE NUMBER
EMAIL ADDRESS

I certify that ______________________________________ is a student enrolled not less than halftime and is in good standing. The duties to be
performed and scheduled hours of work are approved as appropriate for the course of study or training that he/she is pursuing. I understand the services
rendered by the student are to be uncompensated. The student
will
will not be given credit (academic or other) for the volunteer assignment.
(check one)

□

□

I understand that a record of the student's attendance and an evaluation of his/her performance will be provided to this institution when the volunteer
assignment is completed.
SIGNATURE OF EDUCATIONAL INSTITUTION REPRESENTATIVE

MRP FORM 126A
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DATE

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STUDENT VOLUNTEER SERVICE AGREEMENT
SECTION V – PARENTAL OR LEGAL GUARDIAN CONSENT FOR VOLUNTEER UNDER 18 YEARS OF AGE
NAME OF PARENT OR LEGAL GUARDIAN (Print Last and First)
ADDRESS (Include City, State, and ZIP Code)

HOME PHONE NUMBER

MOBILE NUMBER

EMAIL ADDRESS

I affirm that I am the parent/guardian of the above named volunteer. I understand the services rendered by the volunteer are to be uncompensated except
for purposes of tort claims and injury compensation. I understand that the volunteer is not considered a Federal employee and that the volunteer service
is not creditable for any Federal employee benefit. I have read the description of the service that the volunteer will perform. I give my permission for
__________________________________________________________ to participate in the specified volunteer activity.
(Print/Type Name of Volunteer)

SIGNATURE OF PARENT OR LEGAL GUARDIAN

DATE

SECTION VI – EMERGENCY CONTACT INFORMATION
NAME (Print Last and First)
ADDRESS (Include City, State, and ZIP Code)

HOME PHONE NUMBER

MOBILE NUMBER

EMAIL ADDRESS

SECTION VII – VOLUNTEER SERVICE PROGRAM COORDINATOR
NAME (Print Last and First)
OFFICE LOCATION (Include City, State, and ZIP Code)

PHONE NUMBER

EMAIL ADDRESS

I agree to accept the volunteer service described in Section II in accordance with Departmental Regulation 4230-1.
SIGNATURE OF MRP VOLUNTEER SERVICE PROGRAM COORDINATOR

DATE

Return completed form by email to [email protected]

MRP FORM 126A
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