# Appendix B.2 – Sample Enrollment Form

Appendix B.2 - Sample Enrollment Form

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*Version 2020.4*Pg. 3*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://www.nationalservice.gov/operations-handbook-appendices.*

**ABC COUNTY RSVP**

**AMERICORPS SENIORS VOLUNTEER ENROLLMENT FORM**

**FOR OFFICE USE ONLY!**

**Station(s)**

**Assignment(s)**

**Date Assigned: ____/____/____**

**Computer Entry: ____/____/____**

**By:**

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

**NameBirth Date**

**Mailing AddressCityZip**

**PhoneCell PhoneEmail**

**Are you a Veteran?**YesNo	**Physical/Medical Limitations**:

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 #_StateExpiration Date

AmeriCorps Seniors 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 an AmeriCorps Seniors volunteer in RSVP, you will be covered by accident, personal liability, and excess automobile 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 as an AmeriCorps Seniors volunteer in RSVP. Please provide the following information.

**Emergency ContactPhone**

**Beneficiary for AmeriCorps Seniors RSVP Supplemental Accident Insurance**:

**NameRelationship**

**Address****Phone**

Employment Experience Special Skills/Interests/Languages Volunteer Experience (Current, Past, Preferred) 

Days/Hours Available: Mon

Tues

Wed

Thu

Fri

MorningsAfternoons

**Please indicate if AmeriCorps Seniors 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 AmeriCorps Seniors  RSVP of ABC County in perpetuity. I will make no monetary or other claim against AmeriCorps Seniors 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 AmeriCorps Seniors 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 AmeriCorps Seniors volunteers in RSVP 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.

**AmeriCorps Seniors Volunteer Signature	Date	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. AmeriCorps 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.

**FOR OFFICE USE ONLY:**

**The following information is optional and will not affect your enrollment with ABC County RSVP**

1. **Occasionally ABC County RSVP will purchase volunteer recognition gifts to a AmeriCorps Seniors volunteer. Please share the size you would use on each item blow.**

2. **Which show of appreciation would mean the most to you? (Check all that apply)**

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3. **AmeriCorps Seniors RSVP is often asked to provide demographical information pertaining to volunteers. Please provide the following information (Optional).**

Are you a Veteran?  

Are you an active Military Member? 

Are any of your family members actively serving in the military? 

(Optional) Gender: 	(Optional) Race/Ethnic Background:

________ Male	___White 	___Asian	___African-American	___Hispanic/Latino

________ Female	___ American Indian/Alaska Native	___ Pacific Islander    ___ Other

Thank you for any information you have provided. Your information is **never**sold, shared, or used outside of AmeriCorps Seniors RSVP, ABC County government or AmeriCorps Seniors.

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