RETIRED AND SENIOR VOLUNTEER PROGRAM

ENROLLMENT FORM

NAME:  Miss  _______________________________________________________  DATE: ___________

               Mrs.    (Last)                                          (First)

               Mr.

ADDRESS: ____________________________________________________________________________

                     (Street)                                                     (Town)                  (State)                    (Zip Code)

Date of Birth: ___________________________  Telephone: _____________________________________

Physical Limitations (if any): ______________________________________________________________

Emergency Contact:  Name: ______________________________ Phone #: _________________________

                                  Address: ______________________________________________________________

PLEASE LIST ANY SPECIAL SKILLS, ABILITIES, OR AREAS OF INTERST:

_______________________________________________________________________________________

I understand that if I use my personal automobile in my volunteer service I will arrange to keep in effect automobile insurance equal to the minimum requirement of our state.

Drivers License #: ____________________________________

Insurance Company: __________________________________  Address: ___________________________

  (If applicable)

As an RSVP volunteer you receive supplemental accident and liability insurance. This is not a substitute for any insurance you may now carry, and only applies while you are performing your assignment as a volunteer in the program and while on your way to and from your volunteer site. Since there is an accidental death benefit involved, you are asked to name a beneficiary.

Beneficiary: ___________________________________  Address: _________________________________

I agree to keep a record of my volunteer hours and send in a time sheet each month. I understand that I must contribute at least 3 hours of service for every ninety days to remain an active member.

County:              ? Clay               ? Moultrie

              ? Effingham          ? Shelby                                                 ______________________________

                                                                                                               (Volunteer Signature)

__________________________________                                             ______________________________

  (RSVP County Coordinator Signature)                                                        (RSVP Director Signature)

Who referred you to RSVP? _______________________________________________________________

Would you like to be called for short term volunteer assignments?            YES                 NO

Do you have a friend who would like to become a RSVP member? ________________________________

Contact information of friend: _____________________________________________________________