Appendix B.2 - Sample Enrollment Form printable pdf download

Appendix B.2 - Sample Enrollment Form

Appendix B.2 – Sample Enrollment Form

FOR OFFICE USE ONLY!

Station(s)

Assignment(s)

Date Assigned: ____/____/____

Computer Entry: ____/____/____

By:

ABC COUNTY RSVP ENROLLMENT FORM

Please print and complete all sections. Forms with original signatures are required for enrollment.

Name

Birth Date

Mailing Address

City

Zip

Phone

Cell Phone

Are you a Veteran?

Physical/Medical Limitations:

Yes

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

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.

Driver’s License #_

State

Expiration Date

RSVP provides a mileage reimbursement for travel between home and volunteer site to the volunteers.

Will you be claiming a mileage reimbursement for travel to and from your volunteer location? Yes__ No__

If Yes, is 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

Version 2017.4

Pg. 1 of 3

This document is provided as a sample ONLY. Its use is optional and, if used, it should be customized as appropriate. For all appendices,

including editable versions of samples and templates, visit https://

Appendix B.2 - Sample Enrollment Form