Rsvp Senior Volunteer Program Registration Form printable pdf download

Retired and Senior Volunteer Program

RSVP Senior Volunteer Program

of Eastern Iowa & Western Illinois

Registration Form

729 34

Ave.; Rock Island, IL 61201

309-793-4425

c/o 215-S. 1

Street; Monmouth, IL 61462

309-428-5841

Bondi Building

(Please print clearly)

311 E. Main St., Suite 518; Galesburg, IL 61401

309-737-3073

__________________________________

_______________________

_____________________

First Name

Last Name

Home Phone Number

Other Phone Number

__________________________________

_______________________

_____

_________________

Mailing Address

City

State

Zip Code

_________________

__________

________

_____________________________

____________

Date of Birth (MM/DD/YY)

Age (55 or over)

Sex (M/F)

E-mail address

County

Emergency Contact Information:

“Like” us on Facebook!

“RSVP of Eastern Iowa and Western Illinois”

______________________________

_______________

Find us on the web!!!

Name/Relationship to You

Phone

____________________________________________

Are you interested in special RSVP projects?

Ethnicity: (optional)

 White/Caucasian  Am Indian/Alaskan Native

 Advisory Council

 Mailings

 Angel Tree

 Asian

 Black/African American

 Driver

 Deliver Meals to Seniors

 Hispanic

 Other

 Special Events

 Tutors/Literacy Program

 Homeland Security/Emergency Programs

Where did you hear about RSVP?

 Friend

 Newspaper

 RSVP Volunteer

 TV/Radio  Staff

 Other:

____________________________________

___________________________________________________

Previous/Current Employer

Do you prefer any specific volunteer assignments?

____________________________________________

________________________________________

____________________________________________

Previous/Current Occupation

As an RSVP volunteer, you are insured for accident and personal

liability while volunteering at a volunteer site. This is strictly a

secondary insurance. Since there is an accidental death

benefit involved, you are asked to name a beneficiary.

____________________________________________

Name of Beneficiary and Relationship to You

____________________________________________

Address of Beneficiary

I certify the accuracy of information I provided and volunteer my services through the Retired and Senior Volunteer Program of

Eastern Iowa & Western Illinois. I also give RSVP permission to use my likeness in publications and promotional materials. I

understand that I am not an employee of RSVP or Western Illinois Area Agency on Aging.

_____________________________________________

______________________________________

Volunteer Signature

RSVP Staff Signature

_____________________________________________

______________________________________

Date

RSVP Director Signature

(PLEASE CONTINUE ON OTHER SIDE)

Rsvp Senior Volunteer Program Registration Form

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