Volunteer Enrollment Form - Pinellas Opportunity Council, Inc.

Name*

First Middle Last

Address*

Street Address Apt.# City State ZIP

Date of Birth:*

Phone*

Email*

Veteran?*

Yes
No

Federal Diversity Reporting Requirements
The following information is for statistical purposes only. Providing this information is voluntary.

Race*

Caucasian
Black
Asian
Pacific Islander
Native American/Alaskan

Ethnicity*

Hispanic/Latino
Non-Hispanic/Latino

Gender*

Male
Female

Physical Limitations (if any)

Skills/ Education/Special Training/Volunteer Experience (if any):

Are you a seasonal volunteer?*

Yes
No

Time Available*

Morning
Afternoon
Evening

Days Available*

Focus Areas and Activities of Interest (check all that apply)*

Veterans
Food Delivery/Distribution
Companion Services
Mentoring/Tutoring
Food Pantry/Soup Kitchen
Medical Driver/Escort
Other

Are you currently volunteering?*

Yes
No

If yes, where?

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

Yes
No

How will you get to your volunteer site?*

Drive
Public Transportation
Friend

INFORMATION FOR VOLUNTEER ACCIDENT INSURANCE

RSVP provides mileage reimbursement for travel between the volunteer’s home and volunteer site. Will you be claiming mileage reimbursement for travel?*

Yes
No

Driver’s License #

State

Driver’s License Expiration Date

As a volunteer of RSVP, you will be covered by accident and personal liability insurance plus a $2,500 death benefit while performing volunteer duties. This coverage is automatic and free of cost to you, so long as you are an active, enrolled member of RSVP.

Emergency Contact*

Emergency Contact Phone*

Beneficiary Name*

Beneficiary Relationship*

Beneficiary Address*

Street Address Apt.# City State ZIP

Automobile*

Insurance*

Company*

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 Pinellas Opportunity Council, Inc. Retired Senior Volunteer Program. I understand that I am not an employee of the RSVP project, the sponsor, Pinellas County, the volunteer station or the Federal Government and agree to serve without compensation.
I understand that in my capacity as an RSVP 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 the automobile liability insurance equal to or greater to the minimum requirements of the state of Florida. I will also keep in effect a valid Florida Driver’s license.

Volunteer Signature*

Date*