Flint Hills Volunteer Center Volunteer Enrollment

Why are you interested in volunteering?*
- I am looking for long-term opportunities where I can help on a regular basis.
- I am looking for short-term, occasional ways to help my community.
- I need service hours for school, fraternity, sorority, etc.
- I need court-ordered service hours.
How many hours do you need? And by when?*
What age group are you in?*
Please select one.

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*
MM slash DD slash YYYY
Age*

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 may prohibit or limit your volunteer options.

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
Would you like to be covered by our excess insurance coverage?*
RSP Volunteers (aged 55 and older) can opt in to be covered under our FREE Excess Volunteer Liability, Excess Accidental Medical, Excess Automobile Liability Insurance, and Accidental Death Coverage. This insurance is secondary to your primary insurance. If you choose to opt in, additional information is requested.
- Opt IN to coverage
- Opt OUT of coverage
RSVP Excess auto liability insurance asks for the following:
Driver's License State Driver's License # Expiration Date
Beneficiary Name
First Middle Initial Last
Address
Street Address Address Line 2 City State ZIP Code
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*
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Volunteer Enrollment