FOR OFFICE USE ONLY!

Station(s) __________________________ 
Assignments________________________
Date Assigned ____/ ____/ ____
Computer Entry ____/ ____/ ____

   	
   
KI BOIS RSVP Volunteer Enrollment Form
Please print and complete all sections.  Volunteer’s signature is required to complete enrollment.

Name ____________________________________________   Birth date _____________________

Mailing or Street Address __________________________________  City, State ______________

Zip ____________ Phone _______________________ Email address _______________________

Ethnic group	⃝ Caucasian    		⃝ African-American    		   	⃝ Hispanic  
⃝ Asian, Pacific Islander	⃝ Native American/Alaskan Native	⃝ Other

Are you a VETERAN?  ___Yes   ___ No   Physical/Medical Limitations _____________________

Driver’s license # _____________________   State _____________   Exp. Date_____________________
RSVP provides a mileage reimbursement for travel between home and volunteer site to volunteers.  Will you be claiming mileage reimbursement?  ___ Yes  ___ No

Have you ever been convicted of a criminal offense or misdemeanor? __Yes  __No  If yes, please attach an explanation of charges, date of offense and status of the charges on a separate sheet to be included with this application.  

If yes, a copy of your proof of auto insurance showing active coverage attached?  ___Yes  ___ No
As a volunteer of RSVP, you will be covered by accident and personal liability insurance plus a small death benefit while performing volunteer duties.  This coverage is automatic and free of cost to you as long as you are an active, enrolled member of RSVP.  Please provide the following information.
 
Emergency Contact _________________________________ Phone ________________________

Beneficiary for RSVP Supplemental Accident Insurance:

Name _________________________________________  Relationship ______________________

Address ___________________________________________  Phone _______________________

Employment Experience ___________________________________________________________

Skills/Interests/Languages _________________________________________________________

Volunteer Experience ______________________________________________________________

Preferred volunteer assignments _____________________  Hours available to work per week ___

Would you like to be included on our Special On-Call List?   ___ Yes  ___ No

SPECIAL ON-CALL LIST – This is a list we refer to when local non-profits are looking for one time assistance with special events or fundraising events.  We will call volunteers on our list when we receive requests for assistance from the non-profits.

Certifications by signing below, I acknowledge that I have read and understand the following statements:
•	I hereby state that I am 55 years of age or older and offer my services as a volunteer for the         KI BOIS RSVP Retired Senior Volunteer Program.  I understand that I am not an employee of the RSVP Program, the sponsor, KI BOIS RSVP, the volunteer station or the Federal Government and agree to serve without compensation.
•	I understand that in my capacity as an RSVP volunteer I may come into contact with confidential information.  I agree to protect this information to the best of my ability and not to disclose it during or after my service as a volunteer has ended.
•	I understand that if I use my personal automobile in my volunteer service, I will arrange to keep in effect automobile liability insurance equal or greater to the minimum requirements of the state.  I will also keep in effect a valid Driver’s license.

Equal Employment Agency - KI BOIS RSVP is an equal opportunity Agency.  Enrollment is done without regard to race, color, religion origin, sex, age or disability.  RSVP provides reasonable accommodations to the known disabilities of individuals in compliance with the Americans with Disabilities Act.  For accommodation information or if you need special accommodations to complete the application process, please contact KI BOIS at (918) 967-3325

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Volunteer Signature			Date		RSVP Staff Signature		    Date