Volunteer Form

Your Name

Gender Identity

Birthday

Email Address

Phone Number

Alternate Number

Previous Employer

Previous Occupation

Race/Ethnic Identity

Are You a Military Veteran?
YesNo
Highest Education Level Complete

Address

Mailing Address

Mailing City

Mailing State

Mailing Zip Code

Physical Address (If different from Mailing)

County of Residence

Language

Do You Speak Another Language?
YesNo

If Yes, What Language?

Medical Limitations

Please Let us Know of Any Medical Limitations that Should be Considered when Arranging Volunteer Assignments

Select All That Apply
WheelchairCane / WalkerCrutchesHearing ImpairedVisually ImpairedBack / Leg DifficultiesOther

Volunteer Availability

To assist us in making your volunteer placement successful, please check all the areas of interest to you.
Homeless ShelterHistorical / MuseumsQuiltingAdult Day CareHome Meal DeliveryReception / ClericalCompanionshipHospitalSenior CentersComputer SkillsKnitting / CrochetingSewingDisaster Relief ServicesLibraryThrift StoreDriver / Escort ServicesMentoring / Tutoring in SchoolsVITA Tax PreparationEnvironmental ActivitiesNutrition SitesOne-Time ProjectsFood Pantries

Emergency Contact

Please provide the name, address and phone number of a person who would be called in an emergency situation.

Accidental Loss of Life Policy

NWCSA-RSVP provides accident and liability insurance for volunteers when they are participating in an NWCSA-RSVP volunteer assignment.

Automobile Insurance Statement

Do You Drive a Car?
YesNo
Will you be claiming mileage reimbursement? (only for those who accrue 100 miles or more per month driving to & from home to volunteer station.)
YesNo

I understand that if I use my personal vehicle driving to and from my volunteer station, I will arrange to keep in effect my automobile lability insurance equal to or greater than the minimum require by the State Of Wisconsin.

Housing

Photo Release

May we use your photo for the specific purpose of publicity, public relations or promotion, providing it is legitimately published?
YesNo

Background Checks are performed by NWCSA-RSVP staff on all volunteers or any Partnering Agency to ensure the safety of vulnerable populations.
NWCSA-RSVP retains all volunteer information in the strictest confidence. No personal information is shared, transferred, or sold to any 3rd party.
NWCSA-RSVP does not discriminate against volunteers, employees or in any operation of any of its programs on the basis of race/ethnicity; color; sex; national origin; including limited English proficiency; age’; political affiliation; sexual orientation; gender Identity or expression; religion; disability, including HIV/AIDS; marital or parental status; military service; past participation in a discrimination complaint process or any other improper criterion.

Confidentiality

I understand that as a volunteer I must maintain privacy and confidentiality of all private and sensitive information connected with the NWCSA-RSVP office and the non-profit organizations utilizing NWCSA-RSVP volunteers. This may include any personal information, business practices and/or related issues connected to volunteering at a station or in the NWCSA-RSVP office. My signature below is my commitment to uphold the spirit of confidentiality.
I will volunteer my services through the NWCAS-RSVP and I understand that I am not an employee of Northwest Wisconsin Community Services Agency Inc., AmeriCorps or the Federal Government. I also hold harmless NWCSA-RSVP, their employees and sponsors from any and all liability resulting from any personal injury received during the course of my volunteer activities.

Personal Information