Appendix B.2 - Sample Enrollment Form (Page 2 of 3) in pdf

Appendix B.2 - Sample Enrollment Form

Employment Experience

Special Skills/Interests/Languages

Volunteer Experience (Current, Past, Preferred)

Days/Hours Available: Mon

Tues

Wed

Thu

Fri

Mornings

Afternoons

Please indicate if RSVP may have permission to use your likeness?

[ ] I hereby grant ABC County 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 RSVP of

ABC County in perpetuity. I will make no monetary or other claim against RSVP of ABC County for the use of

these photograph(s)/video(s).

[ ] I do not give permission to use my likeness in photograph(s)/video(s) to ABC County RSVP.

Certifications

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

• I hereby state that I am 55 years of age or older and offer my services as a volunteer for the ABC County

Retired Senior Volunteer Program. I understand that I am not an employee of the RSVP Project, the

sponsor, ABC County, the volunteer station or the Federal Government and agree to serve without

compensation.

• I understand that 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 that 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

Xxxx. I will also keep in effect a valid Xxxx Driver's license.

RSVP Volunteer Signature

Date

RSVP Staff Signature

Date

Equal Employment Agency - ABC County RSVP is an equal opportunity Agency. Enrollment is done without

regard to race, color, religion, national origin, 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 ABC County RSVP at (555) 555-1234.

Return completed registration to:

ABC County RSVP

For Questions contact:

(Original Signatures

PO Box 123

Jane Doe (555) 555-1234

Required on the Form)

Our Town, USA 81234

RSVP.PD@abccounty.gov

FOR OFFICE USE ONLY:

Version 2017.4

Pg. 2 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 Page 2

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