VOLUNTEER ENROLLMENT FORM

Date received:_______________
Staff initials:________________
VOLUNTEER ENROLLMENT FORM
Please Print
Name: (Last, First, MI)
Today’s Date:
Address:
County:
City:
State:
Home Phone (Home):
Birth Date:
ZIP:
Phone (Cell):
Email:
All RSVP volunteers are covered by our supplementary insurance, free of charge.
Please list your beneficiary for RSVP Accident Insurance:
Name: ____________________________________________ Relationship: ____________________
Address: ___________________________________________________________________________
Phone (H): ______________________________________ (W): _______________________________
In the event of an emergency, please contact:
Name: _____________________________________________ Relationship: __________________
Address: __________________________________________________________________________
Phone (Day): ________________________________ (Evening): ______________________________
How do you plan to travel to your volunteer opportunity? (Please check)
Drive
Work in home
Bus/Metro Mobility
Walk
Complete the following if you plan to drive:
Driver’s License No. ____________________________________
Insurance Company: ___________________________Policy Number: ________________________
Statement of Coverage:
I agree that if I use my personal automobile to travel to and from my volunteer workstation, I will arrange
to keep in effect: automobile liability insurance equal to the minimum required by the State of Minnesota.
Please Initial:____________
Date: ______________________
How did you hear about RSVP?
_______________________________________________________________________________________
Are you currently volunteering?
YES
NO
If yes, please list agency name and job duties:
EnrollmentApplication.2013.Final(SDrive.Procedures.2013Revisions)
Please Continue on the Back ↓
What interests or skills would you like to use as a volunteer?
Are you employed?
Yes
No
Employer/company retired from: _________________________________________________________
Occupation: ___________________________________________________________________________
Are you a military veteran?
Yes
No My spouse is a veteran
I’m a widow/er of a veteran
Are you interested in being on-call for one-time special projects, or serving as an RSVP Ambassador?
Special Projects
RSVP Ambassador
Do you have any health concerns or physical limitations we should know about?
YES
NO
If yes, what are your limitations?
_____________________________________________________________________________________
Have you ever been convicted of a crime? NO YES If yes, describe the nature of the crime:
______________________________________________________________________________________
Is there anything else you wish to share with us?
Do you know anyone over 55 who would be interested in volunteering? YES
NO
If so, please list their name and phone number:
Name: ___________________________________________ Phone number: _______________________
Please sign:
I confirm that the information on this form is true and complete to the best of my knowledge.
I understand and agree that RSVP will conduct a criminal background check.
Signature: ________________________________________________________________________
Please mail, scan and email, or fax this signed form back to RSVP so that we can begin working with you
to find the volunteer opportunity that is right for you. THANK YOU.
The following information is optional. Our funding sources require that we report as able. The information
is submitted in totals only, not by individual. RSVP pledges to protect the confidentiality of all information.
We appreciate your cooperation in answering the following questions. Thank you.
Gender:
Male
Race/Ethnic Group:
Female
_________
Asian or Pacific Islander
African American
Caucasian (white)
Hispanic
Native American
Other ____________
Greater Twin Cities RSVP
Volunteers of America
924 19th Avenue South
Minneapolis, MN 55404
West Metro: 612-704-6114
East Metro: 612-704-6116
EnrollmentApplication.2013.Final(SDrive.Procedures.2013Revisions)
Fax: 888.657.4993
East Central Minnesota RSVP
Volunteers of America
38 N. Union St.
Mora, Minnesota 55051
Tel: 320.679.1245 x 16
Fax: 888.657.4993