Clone of Volunteer Registration Form

Volunteer Registration Form

Serving Mahnomen, Hubbard, Becker, Otter Tail & Wadena Counties

1125 West River Road Detroit Lakes MN 56501 | 1-888-458-1385
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Email Address
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
NOTE: If you are 55 or older, you will be enrolled in AmeriCorps Seniors RSVP.
(Optional) Are you a Veteran?
(Optional) Do you have family members that served in the US Armed Forces?
(Optional) Sex:
(Optional) Race/Ethnicity
Do you have a physical limitation or medical condition that would affect your ability to volunteer at certain sites? (if yes, please explain.)
I am interested in volunteering with:

(Please check any that apply.)
Children
Seniors
Outdoor Activities
Clerical/Office Work
Community Needs
Special Projects
Do you want reimbursement for miles driven while volunteering with AmeriCorps Seniors RSVP?
Supplemental Insurance

All RSVP volunteers are covered by our supplemental insurance, free of charge. Please list your beneficiary for Accident Insurance Policy.
Beneficiary Name/Relationship
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
As an RSVP Volunteer, I receive supplemental liability insurance when commuting to and from assignments. As required, I will keep in effect liability insurance equal to or greater than the minimum required by the State of Minnesota.
Valid Drivers License:
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I do not drive. Please initial: Initials Date:Date
I understand that I am a "Volunteer" of MAHUBE-OTWA, not an employee of the agency.

By signing this form, I hereby give my permission to use my name and/or photograph in news stories, newsletters, etc. to help MAHUBE-OTWA CAP in promoting this program.

The Volunteer Handbook can be accessed via the MAHUBE-OTWA website at www.mahube.org
Volunteer Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
MAHUBE/RSVP Staff Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Mail completed form to:

MAHUBE-OTWA CAP

1125 West River Road

Detroit Lakes, MN 56501
Questions:

Cynthia McDonough

218-847-1385 ext 140

cmcdonough@mahube.org
DISCLAIMER:

This material is based upon work supported by AmeriCorps Seniors, under grant 26SREMN005. Opinions or points of view expressed in this document are those of the authors and do not necessarily reflect the official position of the ACS program.
Age
Should be Empty:

Volunteer Registration Form

I am interested in volunteering with: