RSVP Application | United Way of Lackawanna, Wayne & Pike Counties

Date of Birth

Street

City/State/ZIP

E-Mail

Physical/Medical Limitations:

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

Yes

No

RSVP provides mileage reimbursement for travel between home and volunteer site. Will You be claiming mileage reimbursement for travel to/from your volunteer location?

Yes

No

Emergency Contact

As a volunteer of 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 member of RSVP. Please provide the following information.

Emergency Contact Name

Emergency Contact Primary Phone

Beneficiary

Beneficiary for RSVP Supplemental Accident Insurance:

Beneficiary Name

Relationship

Beneficiary Phone

Beneficiary Address

Employment Information

Employment Experience

Special Skills/Interests/Languages

Volunteer Experience (Current/Past/Preferred)

Please specify Days/Hours Available

Monday

Tuesday

Wednesday

Thursday

Friday

Morning

Afternoon

Please indicate if RSVP may have permission to use your likeness:

I hereby grant RSVP of Lackawanna, Luzerne and Wyoming Counties 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 RSVP of Lackawanna, Luzerne and Wyoming Counties in perpetuity. I will make no monetary or other claim against RSVP of Lackawanna, Luzerne and Wyoming Counties for the use of these photograph(s)/video(s).

I DO NOT give permission to use my likeness in photograph(s)/video(s) to RSVP.

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 Lackawanna, Luzerne and Wyoming Counties Retired and Senior Volunteer Program (RSVP). I understand that I am not an employee of the RSVP Project, United Way of Lackawanna and Wayne Counties, Lackawanna 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 in 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 Pennsylvania. I will also keep in effect a valid Pennsylvania Driver's license.

RSVP Volunteer Signature

Equal Employment Agency - RSVP is an Equal Opportunity Agency. Enrollment is done without regard to race, color, religion, national origin, sex, age or disability. RSVP provides reasonable accommodations to the known disabilities of individuals in compliance with the American with Disabilities Act. For accommodation information or if you need special accommodations to complete the application process, please contact RSVP of Lackawanna, Luzerne and Wyoming Counties at 570.343.1267 x312

Demographic Information (Optional)

RSVP is often asked to provide demographic information pertaining to volunteer members. Please provide the following information (Optional):

Are you a Veteran?

Yes

No

Are you an active Military Member?

Yes

No

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

Gender

Female

Male

Race/Ethnic Background

African American

American Indian/Alaska Native

Asian

Hispanic/Latino

Pacific Islander

White

Other…

Thank You for all of the information you provided. Your information is NEVER sold, shared or used outside of RSVP of Lackawanna, Luzerne and Wyoming Counties or the Corporation of National Community Service.