Fillable Retired and Senior Volunteer Program Registration Form (Durham Technical Community College)

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Retired and Senior Volunteer Program Registration Form (Durham Technical Community College)

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Retired and Senior Volunteer Program
Sponsored by Durham Technical Community College and the Corporation for National and Community Service
1637 Lawson St. Durham, NC 27703 voice: 919-536-7270 fax: 919-536-7283 email: rsvp@durhamtech.edu
Registration Form
Mail or fax the completed, signed form to RSVP.
Date: ____
___________________
Name: ____________________________________________________________________________
Address: ___________________________________________________________________________
City: ______________________________ Zip Code: ________________________________________
Email: ______________________________________________ Telephone: __________________
Date of Birth:__
_____________________ Age: _____________ Ethnicity: ____________________
Method of Transportation:_________ Personal Auto Insurance Carrier: ________________________
Driver’s License #: _______________________________________ Expiration:________________
(This information is requested because RSVP provides free excess liability & accident insurance when you are volunteering.)
Are you a veteran? ☐ Yes ☐ No
Volunteer Interests: __
_______________________________________________________________
__________________________________________________________________________________
Previous Occupation, Training, or Education: _____________________________________________
Please lists any special interests or hobbies: ______________________________________________
__
________________________________________________________________________________
Do you speak a foreign language: ______
__ If yes, which language(s): _________________________
Please explain any physical limitations: ___________________________________________________
___________________________________________________________________________________
How did you learn about RSVP? _________________________________________________________
Rev 5/2016
_________________________________________________ ___________________________
_________________________________________________ ___________________________
Person to Notify in Case of an Emergency:
Name: _________________________________ Relationship: _____________________________
Address: __________________________________________________ Telephone: ____________
References-Please provide contact information for two people who are not related to you.
Name_______________________________ Name_______________________
Email_______________________________ Email________________________
Phone #_____________________________ Phone____________________________
☐ I certify that I volunteer my services through the Retired and Senior Volunteer Program and
understand that I am not an employee of Durham Technical Community College or RSVP.
☐ I certify that I have received a volunteer handbook, a volunteer assignment description, and
information on access to time sheets.
☐ I authorize release for my image, voice and quotes to be used by RSVP and Durham Tech for
recognition and/or program marketing and promotion in print, website and social media.
Designation of Beneficiary for RSVP Accident Insurance
Name: ____________________________________________ Relationship: ___________________
Address: __________________________________________________________________________
City: _______________________________________________ State: _____ Zip Code: _________
I declare that all of the statements made in this application are true, complete, and correct to the best
of my knowledge and belief.
Signature of Volunteer Date
Signature of RSVP Coordinator Date
Rev 5/2016
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Retired and Senior Volunteer Program Registration Form (Durham Technical Community College)

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Completed 1 October 2020

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