RSVP Application

General Information

First Name *
Last Name *
Phone *
Email *
Address *
City *
State *
Zip *

Volunteer Data Record

The funding source requires reports that identify volunteers sex, race, age, handicapped and/or veteran status. In order to comply with necessary reporting, record-keeping and other requirements, please complete this Volunteer Data Record.

This information maye be used to determine other (GECAC) programs that may benefit you.

Submission of information is voluntary and is not a condition of acceptance.

Date of Birth
mm/dd/yyyy
Sex
Ethnicity
Age Group
Veteran
Period Served
Education
Marital Status
Any Physical Limitations
If yes, please describe
Housing
Income
Annual Income Range

Background Information

Do you have your original Act 33 form
Criminal Clearance
Date of Issue
Do you have your original Act 34 form
Child Abuse Clearance
Date of Issue
Groups of individuals you prefer to work with *
Select all that apply.
Please identify all areas of interest
Select all that apply.
Previous Work Experience
Volunteer Station (1)
Position
Volunteer Station (2)
Position

Transportation

How will you travel to and from your volunteer workstation?
Driver License No.
8 Digits
Expiration Date
mm/yyyy

I understand that if I use my personal vehicle in traveling to and from volunteer activities, I must have, and keep in affect, auto insurance equal to the minimum limits required by the State of Pennsylvania.

I acknowledge that I have read and understand the above statement

Emergency Contact

First Name
Last Name
Relationship
Phone
Address
City
State
Zip

Beneficiary for RSVP Accident Insurance

(Provided by the Program)

First Name
Last Name
Relationship
Phone
Address
City
State
Zip
Referred to RSVP by