RSVP Volunteer Registration

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Best Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date*

MonthDayYear

Current Age

Skills/areas of Interest

YesNo

Previous occupation or work experience

Physical conditions for consideration in making volunteer assignments

YesNo

As an RSVP volunteer, you will receive free liability and life insurance effective during actual volunteer service. If you are a volunteer driver, insurance coverage will include auto liability as well.

For RSVP Supplemental Insurance, responses to the next three questions are mandatory:

Person to notify in case of emergency*

Phone of emergency contact person*

Please enter a valid phone number.Format: (000) 000-0000.

List beneficiary’s name for insurance*

As an RSVP volunteer, I may learn confidential information about those I serve and/or those with whom I serve (students, transportation clients, clients at volunteer stations, other volunteers...) I agree not to discuss confidential information concerning any parties/individuals I encounter through service as an RSVP volunteer. (Examples: names, addresses, type and amount of service, information concerning social or economic circumstances, medical care, etc.) I agree to respect and protect this information to the best of my abilities as a volunteer and not to disclose it during or after my service as a volunteer has ended.

Volunteer Signature*

Date*

Date

From time to time, photos will be taken of volunteers for use in promotions for the RSVP Volunteer Program.

PUBLICITY/IMAGE/VOICE PERMISSION

The RSVP Volunteer Program in Northwest Iowa normally takes photographs, video, and/or tape recording of our volunteers in action. During activities, a photograph or video/audio recording may be taken of you. Unless you request otherwise, your consent below will be considered permission for the Northwest Iowa RSVP Volunteer Program to photograph, film, audio/video tape, record and/or televise your image and/or voice for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions.

I agree for my image/voice to be used in promotions for the Northwest Iowa RSVP Volunteer Program:

Signature

Date