Volunteer Membership Application
Sponsored by Triton College
2000 Fifth Ave., River Grove, IL 60171 (708) 456-0300, Ext.3835 or 3603
(Please print and answer all questions.) Date: ______/______/_______
Name______________________________________ Address________________________________________
City_________________________________ ZIP______________ Township __________________________
Phone No. (____) _______________________ Alternative Phone No. (_____) __________________________
Date of Birth____/____/____ E-mail Address ____________________________________________________
Emergency Contact__________________________________ Phone Number(_____) _____________________
Volunteers serve without compensation, but upon request volunteers can receive transportation reimbursement
from our grant funding. To receive mileage or transportation reimbursement you must answer the questions below
and be the individual driving the automobile or taking public transportation to and from your volunteer assign-
ment.
Do you intend to ask for reimbursement? _____ No _____ Yes
Mode of transportation to volunteer assignment (check one)
Car _____ Driver or_____ Passenger _____ Taxi _____ Public Transportation
Insurance Statement for Volunteer Driving a Car
I, _________________________________, as the RSVP volunteer, understand that if I use my personal automo-
bile in volunteer service, I will keep in effect automobile liability insurance equal to the minimum limits required
by the state.
Driver’s License Number
(NOT Plate Number) _______________________________________ Expiration Date_____/_____/_____
Your Insurance Carrier _____________________________________ Expiration Date _____/_____/_____
RSVP Accident Insurance—Designation of Beneficiary
Name _______________________________________ Relationship _____________________________
Address _____________________________________ Phone Number (_____)____________________
Employment Experience _______________________________________________________________________
Skills/Interest/Languages ______________________________________________________________________
Volunteer Experience _________________________________________________________________________
I’m a veteran. Yes_____ No_____
What days are you available? ___________________________________________________________________
What hours are you available? __________________________________________________________________
Enrollment Statement
I, ________________________________, volunteer my services through Triton College RSVP to serve my com-
munity. I understand that I am not an employee of RSVP, Triton College, the federal government or the agency
where I volunteer.
Signature of Volunteer________________________________ Date _____________________________
Signature of RSVP Staff ___Kay L. Frey_______________ Date ______________________________
¨If you are already volunteering, please list the agency, location and volunteer assignment.
Agency/Location ____________________________________ Volunteer Assignment ________________
FOR OFFICE USE ONLY
Agency Assigned __________________________________________________ Date Assigned _____________________
Welcome Packet Sent ________________________ Entered in Computer __________________ By ___________
Volunteer Assignment Options
To guide us in placing you in the proper volunteer opportunity, please check one or more of the following areas
you would be interested in pursuing.
Advisory Council (RSVP)
Children’s Activities
Computer/Data Entry/Internet
Conversation Tutor-ESL
Driver/Delivery
Education
Food Pantry
Fund Raising/Grant Writing
Handyman
Hospice/Respite
Hospitals
Kitchen/Nutrition
Library/Reading
Marketing
Meals on Wheels
Mentally/Physically Challenged
Nursing
Office Aide/Clerical
Patient Advocate
Public Safety
Reading
Reception/Hospitality
SPOT Volunteer (Special
Placement One Time)
Surgery-Waiting Room
Tax Counseling for the Elderly
Thrift/Gift/Resale Shops
Tutoring
Visiting Patients
Volunteer Recruitment
I prefer this geographic area:
Near West Suburban Cook
County
Far West Cook County
Southwest DuPage County
I prefer working with the follow-
ing age groups:
Pre-school
Elementary
Junior High
High School
Adults
Seniors
No Preference
If upon completion, you are un-
able to choose an assignment,
geographic location or group
preference, an RSVP staff mem-
ber will assist you.
Please call
(708) 456-0300, Ext. 3835.
072012
click to sign
signature
click to edit
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