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.)
Location*
Volunteer Information
Name*
First Middle Initial Last
Address*
Street Address Address Line 2 City State ZIP Code
Please list local address if it differs from your permanent address.
Phone*
Email
Birth Date*

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 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.
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.
Referred by:
How did you hear about the Flint Hills Volunteer Center?
Current Volunteer, Community Agency, Staff, Internet, etc.

Volunteer Experience & Interest
Are you volunteering at this time?
- Yes
- No
If yes, where?
Please list previous places/positions of volunteer work.
Please list any education, trainings, certifications, etc.
Please check any skills and interests that you may be willing to invest:*
These skills and interests will be helpful in finding a good fit for you with our different partner agencies and positions available. (Hold CTRL to select multiple interests.)
Please share any other skills/interests not listed:

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*
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Volunteer Information