Name:

, , NY

Residence: Street, City, State, Zip

() - () -

Home Phone Cell Phone E-Mail Address

Date of Birth: Male Female

Veteran/Military Service Veteran/Military Spouse Active Duty/Nat’l Guard/Reserves Family member actively serving

Ethnicity: Bi-lingual? Yes No What Language(s)?

Retired From:

Position:

Highest Level of Education:

How did you hear about Steuben County RSVP? Second Seasons Newspaper Internet Other:

Referred by another RSVP member? Yes No If so, then who?

Have you ever volunteered with RSVP before? Yes No Where?

Are you a person with disabilities? Yes No Please describe:

Have you ever been convicted of an offense against the law other than a minor traffic violation? Yes No

If Yes, please explain:

Emergency Contacts (Please provide two if possible):

Contact 1:
Name:
Relationship:
Phone #:() -
Cell Phone #: () - / Contact 2:
Name:
Relationship:
Phone #: () -
Cell Phone #: () -

Areas of Interest:

RSVP is committed to serving our community in areas of need. To help us provide you with volunteer opportunities that complement your skill, talents, and interests, please check off any categories which pertain to your interests and experience.

Health and Nutrition
Meal Delivery
Food Pantry
Meal Sites
Bone Builders
Medical Transportation
Friendly Visitor
Grocery Delivery/
Shopping Assistant
Support Services
(i.e. Information Desks)
Children (K-12)
Mentoring
Reading/Tutoring
Literacy / Public Safety
Disaster Preparedness
Emergency/Safety
Support
Blood Drives
Community and Economic Development
Transportation Services
Tax Form Preparation
Financial Counseling
Community Events
Advisory Council/Board
Member
Environmental
Wildlife/Wetland
Protection
Environmental Awareness / Arts & Culture
Docent
Host
Historical
Research/Recording
Other
Clerical
Special Events/On-Call
List
Working with Veterans
and/or Military Families
Hospice Support
Nursing Home
Companionship

Are you a licensed driver? Yes No License #: Expiration:

Would you be willing to transport others? Yes No

Would you like reimbursement for mileage? Yes No

Vehicle Inspection up to date? Yes No / Auto Insurance Company
Policy Number / Liability Coverage Amount

*Drivers License and proof of insurance will be verified to qualify you for Steuben County excess automobile insurance. Insurance offered to volunteers is supplemental to your current insurance policy, which must be at least the minimum amount required by New York State Law. RSVP only offers coverage while you are traveling to or from, and performing duties specific to your volunteer assignment.

As an RSVP Volunteer, you are entitled to participate in our insurance program at no cost to you. This program will supplement your existing insurance coverage should you experience an accidental injury, and provide a beneficiary with $2500.00 should accidental death occur while on a volunteering assignment for RSVP. In order to collect benefits, a beneficiary must be named.

Do you wish to designate a beneficiary? Yes No

Beneficiary’s Name:

Beneficiary’s Relationship:

Beneficiary’s Address:

Beneficiary’s Phone Number: () -


RSVP Volunteers - Lead With Experience

Last modified 10/2013 CT