Step 1 of 4 - About You 25% Name First Last PhoneAlternate PhoneEmail Date of Birth If you are age 55 or better, you will automatically receive RSVP 55+ Volunteer Program benefits. Details and opt-out box are located at the end of this application.GenderMaleFemalePrefer not to answerAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Emergency Contact First Last Emergency Contact PhoneEmergency Contact RelationRacial Group American Indian or Alaskan Native Asian Black or African American White or Causacian Native Hawaiian or Pacific Islander Prefer not to answer Primary InterestCaring CompanionsEndwright CenterGarden ClubHome Delivered MealsMobile Food PantryMoney ManagementOffice SupportPatriot PalsSafe at Home/REPAIRS TeamVASIA (Volunteer Advocate for Seniors or Incapacitated Adults)Volunteer from HomeUndecidedSecondary InterestCaring CompanionsEndwright CenterGarden ClubHome Delivered MealsMobile Food PantryMoney ManagementOffice SupportPatriot PalsSafe at Home/REPAIRS TeamVASIA (Volunteer Advocate for Seniors or Incapacitated Adults)Volunteer from HomeUndecidedAdditional Interests Caring Companions Endwright Center Garden Club Home Delivered Meals Mobile Food Pantry Money Management Office Support Patriot Pals Safe at Home/REPAIRS Team VASIA (Volunteer Advocate for Seniors or Incapacitated Adults) Volunteer from Home Undecided How long do you plan to stay as an Area 10 volunteer?Available Start Date Do you have your own reliable transportation?YesNoHow many hours per week would you like to volunteer?Plesae select the times you are available to volunteer.Monday-MorningMonday-AfternoonMonday-EveningMonday-Any timeTuesday-MorningTuesday-AfternoonTuesday-EveningTuesday-Any timeWednesday-MorningWednesday-AfternoonWednesday-EveningWednesday-Any timeThursday-MorningThursday-AfternoonThursday-EveningThursday-Any timeFriday-MorningFriday-AfternoonFriday-EveningFriday-Any timeSaturday-MorningSaturday-AfternoonSaturday-EveningSaturday-Any timeSunday-MorningSunday-AfternoonSunday-EveningSunday-Any timeTo select multiple times, hold down the shift key on your keyboard while clicking.Please select your desired location.Bloomington-NorthBloomington-SouthBloomington-EastBloomington-WestBloomington-DowntownSmithvilleUnionvillePoland/CunotEllettsvilleStinesvilleSpencerCloverdaleGosportBowling GreenOtherTo select multiple locations, hold down the shift key on your keyboard while clicking.Are you a veteran or active military?YesNoAre you CPR/1st Aid Certified?YesNoAre you a current student?YesNoDoes volunteering count for a class?YesNoIf yes, which course number, name of professor, total hours required, etc.?Have you ever been convicted of a felony?YesNoDo you have any charges pending?YesNoIf yes, please provide explanation.A charge or conviction does not necessarily mean that you are not able to volunteer. ReferencesReference 1:(name, and address or phone number)Reference 2:(name, and address or phone number)Reference 3:(name, and address or phone number)SkillsThe following questions are optional.What is your educational background/program of study?Please list special skills and qualifications.Please list any experiences that could contribute to service (personal and/or professional).Do you speak, write or understand any language other than English?YesNoLanguage(s)Why do you want to volunteer for this program?Please list any additional information you would like us to consider.How did you hear about Area 10? RSVP 55+ Volunteer ProgramRSVP 55+ Volunteer Program is a corps of volunteers (all age 55 and better) making a difference in our community. Numbering over 475 strong, RSVP volunteers serve in a variety of focus areas. Joining RSVP helps Area 10 by allowing your service activity to be reported to local, state, and federal agencies, letting them know the impact of your volunteer time and expertise. To learn more about the RSVP 55+ Volunteer Program, click here.RSVP Opt-out: Please DO NOT enroll me in RSVP AcknowledgementI verify that all of the information above is correct and true to the best of my knowledge. I am interested in volunteering at Area 10. I understand that all information is kept strictly confidential. I give Area 10 the right to investigate all references. I hereby release the use of my photograph, and understand that the photograph may be used for a variety of purposes, including, but not limited to, newspapers, websites, brochures, and newsletters. I release RSVP and Area 10 Agency on Aging from any claim which may arise from participation in RSVP or Area 10 activities. My signature also verifies my permission to run a criminal back-ground check and to share this information with any agencies with which I volunteer. I agree to notify Area 10 immediately if anything changes that would affect the results of my background check.SignatureToday's Date NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.
