Appendix C.2 - Sample AmeriCorps Seniors FGP-SCP Volunteer Enrollment Form

# Appendix C.2 – Sample AmeriCorps Seniors FGP-SCP Enrollment Form

**FOR OFFICE USE ONLY**

**Station(s) __________________________________**

**Assignment(s) ______________________________**

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

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

**By:________________________________________**

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**ABC COUNTY FGP/SCP**

**AMERICORPS SENIORS VOLUNTEER ENROLLMENT FORM**

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

**Name**_____________________________________ **Birth Date**____________________ **Age**_________

**Mailing Address**___________________________**City**________________________ **Zip**____________

**Phone** _________________**Cell Phone** ___________________**Email** __________________________

Have you ever been convicted of a **criminal offense or misdemeanor**?  Yes___  No___  **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.   

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Driver’s License #______________________________ State_________ Expiration Date_________________

AmeriCorps Seniors SCP/FGP 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 a AmeriCorps Seniors volunteer, you will be covered by accident and personal liability 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 member of AmeriCorps Seniors FGP/SCP.  Please provide the following information.

**Emergency Contact**___________________________________________**Phone**________________________

**Beneficiary for AmeriCorps Seniors FGP/SCP Supplemental Accident Insurance**:

**Name**______________________________________**Relationship**______________________________	

**Address**____________________________________**Phone**___________________________________

**The following information will help AmeriCorps Seniors FGP/SCP match you with a volunteer opportunity:**

Employment Experience__________________________________________________________________________

Special Skills/Interests/Languages______________________________________________________________

Volunteer Experience (Current, Past, Preferred) ___________________________________________________________________________________

Days/Hours Available: Mon___    Tues___    Wed___    Thu___    Fri___	 Mornings___ 	Afternoons___

Do you require any special accommodations or have physical or medical considerations that may impact a volunteer assignment?****___________________________________________________________________

**Please indicate if AmeriCorps Seniors FGP/SCP may have permission to use your likeness?**

**[  ]**   I hereby grant ABC County FGP/SCP 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 FGP/SCP of ABC County in perpetuity.  I will make no monetary or other claim against AmeriCorps Seniors FGP/SCP 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 FGP/SCP.

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**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 FGP/SCP Program.  I understand that I am not an employee of the AmeriCorps Seniors FGP/SCP Project, the sponsor, ABC County, the volunteer station or the Federal Government.

· I understand that in my capacity as an AmeriCorps Seniors 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 _____.  I will also keep in effect a valid [State] Driver's license.

_________________________________________	_________________________________________

**AmeriCorps Seniors Volunteer Signature	   Date		Staff Signature		Date**

**Equal Employment Agency** - ABC County FGP/SCP is an equal opportunity Agency. Enrollment is done without regard to race, color, national origin, gender, sexual orientation, religion, age, disability, political affiliation, marital or parental status, or military service. AmeriCorps Seniors FGP/SCP 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 FGP/SCP at (555) 555-1234. 

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Return completed registration to:	ABC County FGP/SCP			For Questions contact:

[**Original Signatures**			PO Box 123				Jane Doe (555) 555-1234

**Required on the Form]**		Our Town, USA 12345 	            FGP/SCP.PD@abccounty.gov

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**The following information is optional and will not affect your enrollment with ABC County FGP/SCP.**

**1.  Occasionally ABC County FGP/SCP will purchase volunteer recognition gifts to AmeriCorps Seniors volunteers.  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)**

**3. AmeriCorps Seniors FGP/SCP is often asked to provide demographical information pertaining to volunteer members.  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 the information you have provided.  Your information is **never** sold, shared, or used outside of AmeriCorps Seniors FGP/SCP, ABC County government or the AmeriCorps Seniors.

*Version 2020.3*Pg. 2*of 4*

*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.*

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