Record of Volunteer Service

RECORD OF VOLUNTEER SERVICE

Volunteer Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
(Attach Proof of Age if Volunteer is Under the Age of 18)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
As a volunteer, I agree to abide by all applicable rules and regulations of Southern Illinois University and guidelines of this unit/department and to fulfill the volunteer responsibilities to the best of my ability. I understand that I will receive no monetary benefits in return for the volunteer service I provide and that I am not covered by the State of Illinois Self-Insured Workers’ Compensation Program. I further understand and agree that the University shall not be responsible for any injuries to me or damages to my property that may occur in the course of the volunteer service. I agree to indemnify and hold the University harmless to the extent permitted by law for any such injuries or damages. I further understand the University may terminate this agreement at any time without prior notice
By signing I agree to assist the certified Rock Steady Coaches and the participants with:
- Class set up/clean up
- Provide individualized assistance to various participants throughout the session
- Be encouraging and supportive of participants’ efforts
- Assist in maintaining a safe work out environment
Volunteer Signature

Clear
Complete Only if Volunteer is Under 18
As parent/guardian of blanks , I grant my permission for him/her to participate as an unpaid volunteer for Southern Illinois University. I further acknowledge that I have completed an Authorization for Treatment form on his/her behalf.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Today's Date

MonthDayYear
Date
What Class are you Able to Volunteer at?

Tuesday (11 - Noon)Thursday (11 - Noon)Both
Should be Empty:

RECORD OF VOLUNTEER SERVICE

Complete Only if Volunteer is Under 18