Form: RSVP Volunteer Enrollment

Step 1 of 8

Name*

First Last

Birth Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Cell Phone

Email*

Have you ever been convicted of a criminal offense or misdemeanor?*

Yes

If yes, please provide an explanation of charges, date of offense, and status of the charges.*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Beneficiary Name*

As an RSVP volunteer, you will be provided secondary coverage for 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 beneficiary information.

First Last

Beneficiary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Beneficiary Phone*

Your Relationship to Beneficiary*

Equal Employment Agency

YWCA RSVP is an equal opportunity Agency. Enrollment is done without regard to race, color, religion, national origin, including individuals with limited English proficiency, 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 YWCA RSVP at (309) 662-0461. Thank you for any information you have provided. Your information is never sold, shared, or used outside of the YWCA RSVP, our participating volunteer stations, or the Corporation of National and Community Services.

Certifications

By signing below, I acknowledge that I have read and understood the following statements:

• I hereby state I am 55 years of age or older and offer my services as a volunteer for the YWCA RSVP. I understand I am not an employee of RSVP, the sponsor, YWCA Mclean, the volunteer station or the Federal Government and agree to serve without compensation.

• I understand 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 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 of Illinois. I will also keep in effect a valid Illinois Driver's license.

• I understand my enrollment form may be scanned as a digital copy for RSVP’s records, and if/when this occurs, my original enrollment form will be shredded.

Signature*

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Enroll in RSVP: Volunteers

Driver’s License Information

Your Interests

Photography Permission

Demographics

Equal Employment Agency

Certifications

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