Volunteer Enrollment Form

Volunteer Enrollment Form Word Download

 

Erie County Department of Senior Services - RSVP Volunteer Enrollment Form

Please Print

Your information will be held strictly confidential.                                           

PERSONAL INFORMATION:

 

Name:____________________________________________________________________________________

             (Mr./Mrs./Ms./Miss.)                        (First)                          (MI)                            Last)

 

Address:_______________________________________ City:_________________________  Zip:________

 

Home phone:_(___)________________       Cell phone:_ (___)_________________

 

Date of birth: ____/____/____                      Email:________________________________________________

 

Ethnic Group (Optional –for statistical analysis only)

 

__African American   __ Caucasian   __Hispanic   __Asian/Pacific Islander   __Native American      __Other

 

Do you have any physical/medical limitations?   __ Yes    __No

If “Yes”, please explain: _____________________________________________________________________

 

Are you a United States Veteran?   __ Yes     __ No

 

EXPERIENCE:

 

Are you retired? __ Yes   __No         Previous/current occupation:  ____________________________________

                                                            Previous/current employer: _____________________________________

 

How did you hear about RSVP? ______________________________________________________________

 

Are you currently volunteering? __ Yes    __No

If “Yes”, where? ____________________________________________________________________

 

Briefly explain your volunteer duties:____________________________________________________

 

Are you interested in additional volunteer assignments?   __Yes    __ No

 

I am interested in volunteering at a specific organization: ____________________________________

                                                                                                                        (Name of organization)

I prefer volunteering in a certain area(s) e.g.: Depew _________________________________

 

When are you available to volunteer?          

                                                                           Mon.    Tues.    Wed.   Thurs.   Fri.      Sat.      Sun.

                                                Mornings         ____    ____    ____    ____    ____    ____    ____

                                                Afternoons       ____    ____    ____    ____    ____    ____    ____

                                                Evenings         ____    ____    ____    ____    ____    ____    ____

           

TRANSPORTATION INFORMATION:

 

Will you be driving to your volunteer assignment?  __ Yes   __ No     If “Yes”, please complete:

 

Will you be requesting mileage reimbursement?    __Yes   __ No

Please note your SSN will be REQUIRED to receive any travel reimbursement from Erie County RSVP.

NOTE: The information below is required in order for you to receive mileage reimbursement and to be covered under the supplemental automobile insurance policy provided by RSVP. (IRS guidelines may allow you to deduct volunteer mileage when itemizing taxes.)

 

Drivers License ID #  (9 Digits) _______________________   State: ______   Expiration date: __________

 

Name of Insurance Company: ________________________   Policy number:________________________

Please provide us with a copy of your drivers license & insurance card.

 

BENEFICARY INFORMATION:

Please designate a beneficiary for the supplemental accident insurance provided by RSVP. If you do not wish to designate or do not have a beneficiary, you may write: “To the estate of (your name).”

 

Name:_____________________________________________       Relationship:________________________

Address:___________________________________________       Phone: _____________________________

 

EMERGENCY INFORMATION:

 

Name:_____________________________________________       Relationship:________________________

Address:___________________________________________       Phone: _____________________________

 

PHOTO RELEASE:

I, _____________________________, DO/ DO NOT (CIRCLE ONE) grant RSVP/Erie County Department of Senior Services permission to interview me and/or take my picture for the purpose of promoting the department services and advocacy for older adults.

 

ACKNOWLEDGEMENT & CONSENT:

 

Have you ever been convicted of a felony?  __ Yes   __ No           Child sexual abuse? __Yes   __ No

If “yes”, please explain: ______________________________________________________________________

  • I agree to undergo a National Service Criminal History Check, including the National Sex Offender Registry Database. Volunteer Stations may require an additional background check.  I understand that I may be disqualified for the following: murder conviction, registered on the Sex Offender Registry, refusal to undergo the National Service Criminal History Check & any false statement about my criminal history.
  • I agree that if I use my personal vehicle to travel to and from my volunteer assignment and/or to carry out my volunteer work, I will maintain a valid driver's license and auto insurance.
  • I understand that information on this form is completely confidential. 

My signature is my consent to these statements

 

X______________________________________                 X________________________________________

   Volunteer Signature                         Date                                RSVP Director Signature                     Date

*FOR OFFICE USE ONLY*

Orientation Date:

Copy of Insurance Received:

NSORD Check Date:

Copy of License Received:

 

 

 

ERIE COUNTY RSVP SKILLS & INTEREST FORM

 

Name:_________________________________                     Date:_________ 

*Please print clearly

Please indicate with an X those skills/talents/strengths you wish to share through volunteering!

Skill Set

Basic

Moderate

Advanced

Accounting/ Auditing

 

 

 

Administration

 

 

 

Arts/Crafts

 

 

 

Board member

 

 

 

Bilingual

 

 

 

Bookkeeping

 

 

 

Business

 

 

 

Caregiving

 

 

 

Computer:

 

 

 

Construction

 

 

 

Cooking

 

 

 

Counseling

 

 

 

Data entry

 

 

 

Data analysis

 

 

 

Driving

 

 

 

Event planning

 

 

 

Farming

 

 

 

Financial

 

 

 

Fitness

 

 

 

Fundraising

 

 

 

Gardening

 

 

 

Grant writing

 

 

 

Graphic arts

 

 

 

Greeting / hospitality

 

 

 

Handyman work

 

 

 

Knitting

 

 

 

Legal

 

 

 

Library

 

 

 

Medical/ nursing

 

 

 

Music

 

 

 

Office/ filing

 

 

 

Phone work

 

 

 

Photography

 

 

 

Physical labor

 

 

 

Public relations

 

 

 

Public speaking

 

 

 

Research

 

 

 

Recruitment

 

 

 

Sales

 

 

 

Scheduling

 

 

 

Skill Set Cont.

Basic

Moderate

Advanced

Sewing

 

 

 

Sign language

 

 

 

Social work

 

 

 

Stocking shelves

 

 

 

Supervision

 

 

 

Teaching

 

 

 

Training

 

 

 

Web design

 

 

 

Woodworking

 

 

 

Work outdoors

 

 

 

Work with animals

 

 

 

Work with children

 

 

 

Work with disabled

 

 

 

Work with teens

 

 

 

Work with elderly

 

 

 

Writing/editing

 

 

 

Other:  

 

 

 

Other: 

 

 

 

 

Please indicate which areas are of interest to you by marking an ‘X’ in the box next to it. Please mark all that apply:

Areas of Interest

 

Aging

 

Arts & Culture

 

Clerical Assistance

 

Computer/Technology Assistance

 

Customer Service/Hospitality

 

Disabilities

 

Education & Mentoring

 

Environment & Nature

 

Health Care

 

Hunger & Poverty

 

Transportation

 

One-Day Events/Projects

 

Other:

 

Other:

 

 

Please describe any additional skills &/or talents you would like to share:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Contact

Phone: (716) 858-8526

Erie County Department of Senior Services
95 Franklin Street, 13th Floor
Buffalo, New York 14202

Office hours: Monday-Friday 8:30 am - 5:00 pm