Retired & Senior Volunteer Program

RSVP Senior Volunteer Program		HandsOn Central California
			Registration Form					732 N. Van Ness Avenue
											Fresno, CA  93728   559.237.3101
											Handsoncentralcal.org

NAME__________________________________________________		HOME PHONE__________________________

ADDRESS_______________________________________________		MOBILE PHONE________________________

CITY, STATE, ZIP CODE____________________________________		E-MAIL ADDRESS_______________________

DATE OF BIRTH______/______/________         GENDER_____ M_____F         VETERAN_____YES_____NO        

OCCUPATION___________________________________     LIVE ALONE_____YES_____NO      COUPLE_____YES_____NO    

BILINGUAL_____YES_____NO     SECOND LANGUAGE_______________________________________________________

Are you currently an active RSVP Volunteer____YES____NO    Are you in need of volunteer placement____YES____NO

Are you interested in one-time events (National Days of Service; special events, fundraisers, etc.) _____YES_____NO

Are you interested in Emergency Response Volunteer Training and Disaster Preparedness _____YES_____NO

Please list any health issues, physical or medical limitations that require special accommodation____________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Ethnicity: (for demographic purposes only)
q White/Caucasian    q American Indian/Alaskan Native    q Asian/Pacific Islander    q Black/African American
q Hispanic/Latino     q Other_____________________________

How did you hear about RSVP?
q Friend    q Newspaper    q RSVP Volunteer    q TV/Radio    q Staff    q Event
q Other:  _____________________________

Communication Preference:
qVolunteer Mailing List      qDonor Mailing List      qRSVP Newsletter Mailing List     qFundraising Event Mailing List

How will you get to your volunteer site?
q Own vehicle    q Bus    q Walk    q Ride with friend    q Other

If you are driving your own vehicle, please provide all the information below:

Auto Insurance Company__________________________   Auto Insurance Policy Number________________

Auto Policy in Effect from ____________________ to _________________________

Driver’s License Number_________________________  Driver’s License Expiration Date________________

MILEAGE REIMBURSEMENT: Mileage reimbursement is available upon request, and you can contact your RSVP Field Coordinator for details.  Volunteers are responsible for assuring that RSVP has a current copy of their valid driver’s license and liability insurance on file.  Reimbursement will not be issued if information is not valid, if there has been a lapse in insurance coverage, or the driver’s license has expired  at the time of the check issue.  Volunteers are responsible for providing updated information (no exceptions).

____I am requesting Mileage Reimbursement.  Attached is a copy of my valid driver’s license & liability insurance.

____I am NOT requesting Mileage Reimbursement.
										
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SKILLS & INTERESTS	
(Please check all that apply)
S = Skill / I = Interest

    S        I							S        I

	Animals							Interpersonal / Greeter			
	Work w/animals, Humane Society, etc.				Greet people at door, take tickets, seat reservations

	Administrative / Clerical				Knitting / Crocheting
	Computer skills, filing, copying, etc.
									Language / Translation
	Baking / Cooking					Bi-lingual, Spanish, Hmong, sign-language, etc.
												
	Bookkeeping / Accounting				Leadership
									Serve on Boards, Committees, Advisory Councils
	Children							
	Reading to children, crafts, games, daycare			Library Aide

	Clerk / Cashier						Mailings / Preparation
	Cash register, take/exchange money, gift shop			Prepare bulk mailings, stuff envelopes, etc.

	Counseling / Support / Social Services		Meal Site Helper
									Assist at senior meal sites
	Disabilities
	Work w/ adults or children with disabilities			Mentoring
									Youth and adult mentoring
	Emergency / Security / Police / Fire
									Museum Aide
	Entertainment						Docent, art study, tour guide
	Clowns, Santa Claus, balloons, theatre, acting
									Organizational
	Environmental						Organize work assignments, people, events
	Clean-up, awareness, etc.
									Photography / Videos
	Food Bank						
									Public Speaking
	Fitness / Sports						RSVP Community Ambassador, other programs
	Senior Olympics, marathons, biking, aerobics, golf, etc.
									Repair / Maintenance / Chores
	Friendly Visitor						
	Visiting home-bound, nursing home patients			Shopping Assistance
									Assist seniors & shut-ins with shopping
	General
	I can help with anything, conferences, events, etc.			Tax Preparation

	Handicrafts / Painting					Telephone / Receptionist
									Answer phones in an office environment
	Health Services
	Patient assistance, nursing assistant, blood bank)			Transportation
									Deliveries, seniors to doctors, etc.
	Home-Delivered Meals
									Tutor
									Working w/children, adults, literacy programs
List below any other skills or interests you would like to add:

_________________________________________________________________________________

___________________________________________________________________________________________________

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Please put a check mark next to the day(s) of the week that you would like to volunteer:

              Monday            Tuesday             Wednesday           Thursday           Friday          Saturday            Sunday

Hours of the day:

              Mornings         Afternoons        Evenings               All day                No Preference

Please list any areas of certification:________________________________________________

_________________________________________________________________________________

Do you prefer any specific volunteer assignments?_____________________________________

__________________________________________________________________________

Emergency Contact:

Name______________________________________________   Phone__________________________

As an RSVP volunteer, you are insured for accident and personal liability while volunteering at a volunteer site.  This is strictly secondary insurance at NO COST to you.  Since there is an accidental death benefit involved, you are asked to name a beneficiary.

Name______________________________________________  Relationship______________________

Address____________________________________________   Phone__________________________

WAIVER & RELEASE OF LIABILTY FOR ACCIDENTS/INJURY
I agree that my activities as a volunteer for RSVP HandsOn Central California are undertaken at my sole rick, and RSVP HOCC shall not be liable for any claims for injuries or damages whatsoever to my person or property arising out of or connected with actions as a volunteer.  I agree to indemnify and to hold RSVP HOCC harmless for all claims and/or liability for me or to me.  I also agree that this waiver and release shall apply to my heir(s), executor(s), and administrator(s).

IN ADDITION:
I understand that I must keep my driver’s license and my liability insurance in force in order to be eligible for RSVP insurance.

I further understand that by signing this waiver, I give permission to use my image in educational and public relations materials.

I volunteer my services through the HandsOn Central California RSVP Program and I understand that I will be placed in a volunteer position, not a paying job.  My volunteering is at my discretion and does not interfere with job search or employment.

I have carefully read this Waiver/Release, I understand its contents, and I intend to be bound to its terms.

Volunteer Signature___________________________________   Date_________________

For Office Use Only

q	Welcome Call	q	Timesheet Mailed	q	RSVP Information Packet Mailed

Station/Job Matched:   	

Staff Initials:   	

Date: