Volunteer Designation Form
California State University Channel Islands Volunteer Designation Form
PLEASE COMPLETE ALL ITEMS
NAME:
LAST FIRST MIDDLE
DATE OF BIRTH:
MONTH/DAY/YEAR
ADDRESS:
STREET
CITY STATE ZIP
PHONE:
EMERGENCY CONTACT:
NAME PHONE
SPECIFIC WORK LOCATION ON CAMPUS OR IN COMMUNITY:
SUPERVISOR’S NAME: SUPERVISOR’S PHONE:
VOLUNTEER DATES:
MANDATORY
START DATE END DATE
ASSIGNMENT AND SUMMARY OF DUTIES:
Will you be driving a vehicle on University business? Yes No
Will you be traveling on University business? Yes No
Are you receiving academic credit for volunteering? Yes No
Are you a University student or staff or faculty member? Yes No
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 VOLUNTEER DATE
_________________________________________ _______________________
SIGNATURE OF UNIVERSITY ADMINISTRATOR DATE
APPROVING THIS VOLUNTEER DESIGNATION
PLEASE SEND COMPLETED FORM TO RISK MANAGER
Rec Center, North and Potrero Fields
Driver for ________________________sport club.
