Volunteer Enrollment

Time of Volunteer*
- Long-Term Volunteer
- Short-Term Volunteer: Needing hours for school, fraternity, sorority, etc.
- Short-Term Volunteer: Needing Community Service hours (probation, violation, etc.)
If short term, how many hours are you needing?
Is there a deadline that you need to complete your service hours by?

Volunteer Information
Name*
First Middle Initial Last
Address*
Please list local address if it differs from your permanent address.

Street Address Address Line 2 City State ZIP Code
Phone*
Type of Phone:*
Home, Mobile, Work
Email*
Preferred Contact Method*
- Phone
- Email
- No preference
Birth Date*
Date Format: MM slash DD slash YYYY

Have you ever been convicted of a crime other than a minor traffic citation?*
- Yes
- No
If yes, provide the date and disposition.
A conviction will automatically bar you from becoming a volunteer.

Media Release & Promotional Materials
Media Release and Promotional Materials*
I give permission for the Flint Hills Volunteer Center to publish the photographs taken of me and my name for use in FHVC's printed publication and website. I acknowledge that since my participation in publications and websites produced by FHVC is voluntary, I will not receive financial compensation. I further agree that my participation in any publication and website produced by FHVC confers upon me no rights of ownership whatsoever. I release FHVC, it's contractors, and it's employees from liability for any claims by me or a third party in connection with my participation.
- I DO authorize the use of my name and picture for this purpose.
- I DO NOT authorize the use of my name and picture for this purpose.
Referred by:
How did you hear about the Flint Hills Volunteer Center?
Current Volunteer, Community Agency, Staff, Internet, etc.

Transportation and Insurance Statement
Do you drive a car?
Flint Hills Volunteer Center, Inc. (for RSVP volunteers) provides free volunteer excess accident and automobile liability insurance coverage while you are volunteering. This policy is SECONDARY to your primary insurance. All volunteers agree to carry automobile liability insurance coverage equal to or greater than the minimum required by the state of Kansas. You can access further coverage details at www.cima-world.com.
- Yes
- No
RSVP Excess auto liability insurance REQUIRES the following:
Driver's License State Driver's License # Expiration Date

Life Insurance Beneficiary Information
All RSVP members receive free accidental death coverage in the event that something were to happen during your time volunteering. Who would you like to designate as your beneficiary? **Only required for RSVP volunteers (age 55 and up).**
Beneficiary Name
First Middle Initial Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone

Confidentiality Statement
I acknowledge that I will abide by all the confidentiality guidelines set forth in the Flint Hills Volunteer Center Volunteer Handbook. I WILL NOT: Discuss a volunteer or client in front of that person or any other individuals, volunteers, or clients; Discuss a volunteer or client in front of other volunteers, visitors, or staff not directly involved with that volunteer or client.*
- I agree
- I do not agree

Volunteer Signature
By typing your name and dating, you are verifying that all information provided is accurate and truthful.*
First Last
Date*
Date Format: MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Volunteer Information