YWCA RSVP Enrollment Form YWCA RSVP Enrollment Form Please complete all sections to be enrolled in the YWCA RSVP program. RSVP volunteers are paired with non-profit organizations in the community that are in need of volunteers and match your skill set. Step 1 of 8 12% Name* First Last Birth Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Cell PhoneEmail* Have you ever been convicted of a criminal offense or misdemeanor?* No Yes If yes,*please attach an explanation of charges, date of offense, and status of the charges. Driver’s License InformationRSVP provides mileage reimbursement for travel between home and volunteer site to the volunteers.Will you be claiming mileage reimbursement for travel to and from your volunteer location?* Yes No Auto InsurancePlease include proof of auto insurance showing active coverage. You may upload a photo or copy now or mail/drop off a copy at YWCA McLean County. This is required for mileage reimbursement.Max. file size: 500 MB.Driver’s License # State Driver's License was Issued Driver's License Expiration Date MM slash DD slash YYYY 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* How did you learn about RSVP?* Local Agency/Non-profit RSVP Volunteer Online Walk-in Social Media (Facebook, Twitter, etc.) Other Please provide name of agency or volunteer* Other* Please provide website/referring online page* Your InterestsPlease help us make your volunteer experience the best it can be. Please tell us what areas interest you and where your skills lie. This will help us match you with a volunteer opportunity. Please check all that apply.Please check all areas in which you'd like to volunteer.* Animals Arts Bingo Books/Book Sales Carpentry/Construction Children’s Activities (Reading, Mentoring, Teaching, Tutoring) Clerical/Filing/Organizing/Reception Computers Crafts/Sewing/Knitting/Crocheting Crisis Aid Ecology/Environment Food Pantry Gardening Gift Shop/Thrift Store History Hospitals/Clinics/Hospice Mailings Military/Veterans Aid Nursing Homes Sales/Cashier Special Events Transportation Additional Special Skills/Interests/LanguagesVolunteer Experience (Current, Past, Preferred)What day(s) of the week are you available to volunteer? Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of day are you available? Mornings Afternoons Do you require any special accommodations or have physical or medical considerations that may impact a volunteer assignment?* Yes No Please explain any accommodations, physical or medical considerations for your volunteer agency.* Photography PermissionPlease indicate if YWCA RSVP has permission to use your likeness in photography or video. Please check one.* Yes. I hereby grant YWCA RSVP permission to use my likeness in photograph(s)/video(s) in any and all of its publications or on the world wide web, whether now known or hereafter existing, controlled by YWCA RSVP in perpetuity. I will make no monetary or other claim against YWCA RSVP for the use of these photograph(s)/video(s). No. I do not give permission to use my likeness in photograph(s)/video(s) to YWCA RSVP. DemographicsThe following information is optional and will not affect your enrollment with YWCA RSVP. RSVP is often asked to provide demographical information pertaining to volunteer members. Please provide the following information (Optional). Are you a Veteran? Yes No Are you active in any Military Branch? Yes No Are any of your family members actively serving in the military? Yes No Gender Female Male Race/Ethnic Background White Asian African-American Hispanic/Latino American Indian/Alaska Native Pacific Islander Other Other Equal Employment AgencyYWCA 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.CertificationsBy 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*Please use mouse or trackpad to sign your name in the box below. Reset signature Signature locked. Reset to sign again CAPTCHA
