RSVP Volunteer Enrollment FormPositive Maturity, Inc.

Please print and complete all sections.

Name: ________________________________________ Birth date: ___________________________

Street Address: _________________________________ City, Zip: ___________________________

Mailing Address: _______________________________ City, Zip: ___________________________

Phone: ______________________ _ Email Address: ________________________

Cell Phone: _________________________________

Temporary Resident? Yes _____ No _____ If yes, date leaving: _________________________

Out-of-State Address: __________________________ City, State, Zip: _________________________

Ethnic Group: Caucasian _____ African-American _____ Hispanic _____

Education: Grade School _____ High School _____ College _____

Business Classes _____ Other ______________________

Veteran? Yes _____ No _____

Do you drive your own car to volunteer? Yes _____ No _____

If yes, driver’s license #: _________________ State: _________ Exp. Date: ________________I understand that if I use my personal automobile to and from my volunteer station, I will arrange to keep in effect automobile liability insurance equal to, or greater than, the minimum required by the state.

AUTO insurance company: _______________________________________________________

Emergency Contact: ________________________________ Phone: _____________________

Beneficiary for RSVP’s Supplemental Accident Insurance:

Name: _______________________________________ Relationship: ___________________

Address: __________________________________________ Phone: ________________________

Employment Experience: ________________________________________________________

Skills, Interests, Languages: ______________________________________________________

Enrollment Form Template

(RSVP Enrollment Form, Continued)

Volunteer Experience: __________________________________________________________

Preferred Volunteer Assignments: __________________________________________________

___________________________________________________________________________

SPECIAL ON-CALL LIST: Would you like to be on a list that we call when local non-profit groups need one-time assistance with special events or fundraisers?

Yes _____ No _____ Days or Hours Available for on-call: _____________________________

Signature of Volunteer Date

Signature of RSVP Coordinator Date

FOR OFFICE USE ONLY!

Station(s) Assigned: (1) BHN#

(2) BHN#

(3) BHN#

Job Assignment Title(s): (1)

(2)

(3)

Date Assigned:

Entered in Computer:

Entered by:

Enrollment Form Template