Enrollment Form

Volunteer Registration for
RETIRED AND SENIOR VOLUNTEER PROGRAM
627 N Glenstone, Springfield MO 65802 • Phone : (417) 862-3595 • Fax (417) 862-2129
eMail: sbradford@ccozarks.org or bbullock@ccozarks.org website: www.rsvp-springfieldmo.net


Please complete both front and back and mail to address above.
All information is solely for RSVP office use and remains strictly confidential.

Name:____________________________________________________Are you a past member of RSVP? Y N

Mailing Address:____________________________________________________________________________
                                         (Street)                             (City)                           (Zip Code)

Telephone Numbers: Home ____________________ Work:____________________ ext: _________

Cell Phone: ___________________ eMail Address: ___________________________________

Birthdate:___/____/_____ Gender: ___ Male ___ Female          Driver’s License #_______________

If you do not drive, what form of transportation do you use? ___________________________

Physical Limitations:________________________________________________________________________

Ethnicity:  __ American Indian   __ Asian/Pacific    __ African American    __ Hispanic    __ White

Previous Occupation/ Employer:____________________________________________________________

Educational Background:_____________________________________________________________________

How did you hear about RSVP? (If from a friend, please tell us their name):_____________________

Spouse’s Name:_________________Anniversary:____/_____/____ Is spouse RSVP member   Y   N

All RSVP members receive FREE accident insurance. Who would you like as your beneficiary

Name:___________________________________Relationship:______________________Phone:___________

Please list two (2) LOCAL persons we should call in the event of an emergency:

Name:__________________________________Relationship:_______________________Phone:___________

Name:__________________________________Relationship:_______________________Phone:___________




Current volunteer involvement:__________________________________________________



The following information will be used to match you with volunteer opportunities. Please check as many that are of interest as you like, but ONLY those in which you are willing to serve as a volunteer. 


Administrative/Management 
Arts/Crafts 
At-Risk Youth 
Bulk Mail/Zip Coding
Carpentry/Woodwork 
Child Advocacy 
Children
Clerical/Office
Companionship/Outreach
Computers
Computer Instruction
Consumer Protection
Cook/Serve Meals
Crime Prevention
Data Entry 
Disaster Relief/Preparation
Docent 
Drug Education
Entertainment 
Environment 
Food/Clothing Bank 
Food & Nutrition
Friendly Visitation
Fundraising 
Gardening 
Gift Shops
Hand Addressing 
Health/Fitness 
Homebound Shopper 
Hospice/Terminally Ill
Hospital/Medical 
Information Desk
Knitting/Crocheting
Literacy/Tutoring
Mentoring
Mobile Meals
Museums 
Nursing Homes
Receptionist 
Reading Buddy
Senior Advocacy
Senior Centers
Serve as Board Member
Sewing
Special Projects
Stuff/Label (Group) 
Tax Assistance
Telephoning (senior shut-ins)
Telephoning (office)
Theatre/Fine Arts
Tutoring Adults
Van Drivers 
Work at Festivals
Writing
Other (please specify):___________________________________________________________________________

Your special talents/skills:__________________________________________________________________________

Anything else you would like us to know abut you?______________________________________________________

May we use your image in any publication for promotion or otherwise  Y  N

 Signature________________________________________________ Date____________________________