Volunteer Connections Enrollment Form Part 1

Name (including middle initial):
*

Group Affiliation:

Birth Date:
*

Male Female Under 18 Over 18

Email:
*

Phone:
*

Street Address:
*

City:
*

State:
*

Zip:
*

Emergency Contact Person:
*

Emergency Contact Phone:
*

Language(s) Spoken:

Previous/Current Occupation(s):

Skills, Hobbies and Experience:

Do you volunteer now?
Yes No

Where?

Do you receive the Senior Messenger Newspaper?
Yes No

(Our newsletter is part of the Senior Messenger and you will be added to the mailing list if over 50 years old)

Are you willing to help in the community in the event of a disaster?
Yes No

Are you willing to attend disaster preparedness training?
Yes No

I understand that the information provided on this form may be disclosed for the purposes of volunteerism only. I understand that if I use my personal automobile to and from my volunteer work station, I will arrange to keep in effect automobile liability insurance equal to or greater than the minimum required by the state. I agree to keep all information about clients, volunteers or other individuals obtained while volunteering confidential. I understand that I am not an employee of Volunteer Connections (RSVP), the Human Services Council, or of any agency where I may volunteer. I am under no obligation to accept or continue any assignment unless I choose to do so. I understand that some volunteer positions may require additional driving history checks and/or background check information. I affirm that the information I have provided is accurate and that I have read and agree to the statements above.

I agree to these conditions:

Parent/Guardian agreement to these conditions:

Yes No