Northeast Iowa RSVP Volunteer Application Form

Northeast Iowa RSVP

Volunteer Application
Your full legal name *

First Name Middle Name Last Name Suffix
First name I go by *
Date of Birth *

Month Day Year
Age *
Gender
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence *

Allamakee Howard Winneshiek
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email *

Confirmation Email You will enter your email in both boxes
Best way to contact you *

Home phone Cell phone Email

Have you ever been found guilty of child or adult abuse? *

No Yes
Please explain your answer regarding abuse.
Have you ever been convicted of a felony? *

No Yes
Please explain your answer regarding felony conviction.
Note: Your name will be checked on the Department of Justice National Sex Offender Public Website. If your name comes up as a convicted sex offender, you will be contacted by the RSVP staff for clarification. Convicted sex offenders cannot serve as a RSVP volunteer.

Please provide us with a person to contact in an emergency.
Name of Emergency Contact *
Relationship *
Emergency Contact Home Phone

Area Code Phone Number
Emergency Contact Work Phone

Area Code Phone Number
Emergency Contact Cell Phone

Area Code Phone Number
Beneficiary *

My estate
Please check to indicate if RSVP may have permission to use your likeness *

I hereby grant Northeast Iowa RSVP permission to use my likeness in photograph(s), video(s) in any and all of its publications or on the world wide web, whether now known or hereafter existing, controlled by Northeast Iowa RSVP in perpetuity. I will make no monetary or other claim against RSVP for the use of these photograph(s), video(s). Please check with me before using my likeness. I do not give permission to use my likeness in photograph(s)/video(s) to NE IA RSVP.

RSVP provides reasonable accessibility accommodations for qualified candidates upon request. If you need accommodations, please comment below.
Comments
Anything else you'd like us to know?
By submitting this form, I acknowledge the information provided is accurate and that I have read and understand the following statements:

I hereby state that I am 55 years of age or older and offer my services as a volunteer for Northeast Iowa RSVP. I understand that, in my role at RSVP, I am not an employee of Northeast Iowa RSVP, Decorah Public Library, City of Decorah, State of Iowa or the federal government and agree to serve without compensation.

I understand that if I use my personal automobile to drive to and from my volunteer station or during my service I will keep in effect automobile liability insurance equal to or greater than the minimum required by Iowa law. I will also keep in effect a valid driver’s license.

I understand that in my capacity as an RSVP volunteer I may come into contact with confidential information. I agree to protect this information to the best of my ability and not to disclose it during or after my service as a volunteer has ended.

No person shall be excluded from participation at RSVP based upon race, color, national origin, gender, age, religion, sexual orientation, disability, gender identity or expression, political affiliation, marital or parental status, or military service. RSVP provides reasonable accessibility accommodations for qualified candidates upon request.
My typed name here is my signature agreeing to the terms above and submitting this application to NEI RSVP *
Please type your name
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