Volunteer Acknowledgment Form printable pdf download

VOLUNTEER ACKNOWLEDGMENT FORM

VOLUNTEER INFORMATION

Full Name: __________________________________

Social Security #:_____________________

Gender: ___M ____F

Date of Birth: _________________ UIN# ____________________

Address: __________________________________________________________________________

City: _______________________ State/Province: ________

Zip/Postal Code: _______________

Phone: ______________________________

Ethnicity: (select only one): _____ Hispanic or Latino _____ Not Hispanic or Latino

Race: (select one or more):

_____ American Indian/Alaskan

_____ American Indian/Alaskan Native

_____Asian

_____ Black/African American

_____ Native Hawaiian/Other Pacific Islander _____White

When applicable to volunteer activities performed, please provide the following information:

Driver’s License; State of Issue and Number __________ ________________________________

Personal Auto Insurance;

Company & Policy # ______________________________________________________________

DEPARTMENTAL AUTHORIZATION

___________________________ has volunteered to assist the _________________________

(PRINT NAME)

(DEPARTMENT)

with the following activities:______________________________________________________

___________________________________________________________________(“Activities”)

It is expected that Activities will be provided (dates)_______________ to __________________

for approximately ________number of hours

daily

weekly

monthly.

Representative: ______________________________Title:__________________________________

Dept Name: _________________________________Dept. Org Code #:_______________________

________________________________________________

____________________

Departmental Representative Signature

Date

Page 1 of 2

Revised December 2009

Volunteer Acknowledgment Form