COMMUNITY SERVICE ENROLLMENT & SKILLS/INTERESTS INDICATOR

 Name:    Mr.    Mrs.    Miss    Dr.    (Please circle one)                                  Date:________________________

 __________________________________________________________________________________________
Last                                                                                First                                                                         Middle

 Address:____________________________________________________________________________________
                                                                                             City                                             State                    Zip

 Telephone: ______________    Birth Date:________     Sex:___     Email: ________________________________ 

Mode of transportation to volunteer site: Car ______  Bus______  Carpool ______  Other ____________________

 Travel reimbursement is available for volunteers. Will you require this? ____ Yes ____ No

Education:  High School ____  College ____  Advanced Degree ____  Field ________________________________

Previous Employer ______________________________Occupation: ____________________________________

Where would you prefer a volunteer assignment:   _____ My home         _____ My neighborhood 
                                                                            _____My town/city     _____Travel within the county is okay.

Times available to volunteer: Weekdays _____ a.m._____ p.m.  and/or  Weekends _____ a.m._____ p.m.

 Age/Interest Group:   ____ Preschool   ____ School Age            ____ Teenage
                                  ____Adults         ____ Long-Term Care    ____ Mentally/Physically Handicapped

What physical conditions should be taken into consideration in arranging a volunteer assignment for you? ____________
___________________________________________________________________________________________

Please indicate the months you will not be available to volunteer (please circle below):

 Jan   /  Feb  /  March  /  April  /  May  /  June  /  July  /  August  /  Sept  /  Oct  /  Nov  /  Dec

 _________________________________                    ___________________________________________
Volunteer Signature                                                                      RSVP Staff Signature

In an emergency, whom may we notify:                         Beneficiary (Accidental Death)
Name: ______________________________             Name: _________________________________
Address:_____________________________            Address: _______________________________
City/State/Zip: ________________________            City/State/Zip: ___________________________
Telephone:___________________________              Telephone:______________________________

Please indicate your areas of interest from the list below.