Name: __________________________ ____________________ ____________
Last First Middle
Date of Birth: __________________________
Address: __________________________ ____________________ ____________
Street/Apt. # City Zip
Phone Number: _____________________________
Area Code/Phone #
Emergency Contact: __________________________ ____________________
Name Area Code/Phone #
Department: __________________________
Supervisor’s Name: __________________________ ____________________
Area Code/Phone #
Volunteer Dates: __________________________ ____________________
Start Date Termination Date
Assignment and ________________________________________________________________________
Summary of Duties: ________________________________________________________________________
1. Need to drive a vehicle on University business? Yes No
2. Need to travel on University business? Yes No
If yes to 1 and/or 2 above, please provide social security number: ___________________________
Are you receiving academic credit for volunteering? Yes No
Are you a University student or staff or faculty member? Yes
This is to acknowledge that I desire to volunteer my services, performing duties similar to those listed above and that services rendered
by me will be at the direction of the above named supervisor. I will not be compensated for these services. Further, I understand that I
serve at the pleasure of my supervisor.
____________________________________________________________ _______________________
Signature of CSU Volunteer Date
____________________________________________________________ _______________________
Approval of Campus Personnel Date