Volunteer Enrollment Form

Love CDC RSVP

(Retired and Senior Volunteer Program)

Love Community Development Corporation

Sponsor/Grantee
Volunteer Enrollment Form
Please complete all sections. Forms with original signatures are required for enrollment.
Legal Name (As shown on your NC Driver's License or ID)

First Name Middle InitialLast Name
Birthdate

MonthDayYear
Date
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Have you ever been convicted of a criminal offense or misdemeanor? If yes, please attach an explanation of charges, date of offense, and status of the charges on a separate sheet to be included with this application.

YesNo
Explanation of Conviction

Cancelof
Driver's License
License #State
MonthDayYear
Expiration Date
Love CDC RSVP will provide (free) supplemental insurance while enaging in your volunteer duties.
Will you be using your personal vehicle for travel to and from your volunteer location?

YesNo
If yes, is a copy of your proof of auto insurance showing active coverage attached?

YesNo
Upload Proof of Auto Insurance Showing Active Coverage

Cancelof
Emergency Contact Information
As a volunteer of LoveCDC RSVP, you will be covered by accident and personal liability insurance plus a small death benefit while performing volunteer duties. This coverage is automatic and free of cost to you as long as you are an active, enrolled member of LoveCDC RSVP. Please provide the following information.
Emergency Contact NameEmergency Contact Phone Number
Beneficiary for RSVP Supplemental Accident Insurance

NameRelationship
AddressPhone
Volunteer Matching Information

The following information will help Love CDC RSVP match you with a volunteer opportunity:
Employment Experience
Special Skills/Interests/Languages
Volunteer Experience (Current, Past, Preferred)
Days Available

MondayTuesdayWednesdayThursdayFriday
Hours Available

MorningsAfternoons
Do you require any special accommodations or have physical or medical considerations that may impact a volunteer assignment?
Likeness
Please indicate if RSVP may have permission to use your likeness

I hereby grant LoveCDC 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 LoveCDC RSVP in perpetuity. I will make no monetary or other claim against LoveCDC RSVP for the use of these photograph(s)/video(s).I do not give permission to use my likeness in photograph(s)/video(s) to LoveCDC RSVP.
Certifications
By signing below, I acknowledge 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 the LoveCDC Retired & Senior Volunteer Program. I understand that I am not an employee of the RSVP Project, Love Community Development Corporation (the sponsor), Forsyth or Stokes Counties, the volunteer station or the Federal Government and agree to serve without compensation.
- 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.
- I understand that if I use my personal automobile in my volunteer service, I will arrange to keep in effect automobile liability insurance equal or greater to the minimum requirements of the State of North Carolina. I will also keep in effect a valid North Carolina Driver's license.
RSVP Volunteer Signature and Date

Clear
RSVP Staff Signature and Date

Clear
Equal Employment Agency - LoveCDC RSVP is an equal opportunity Agency. Enrollment is done without regard to race, color, religion, national origin, sex, age or disability. RSVP provides reasonable accommodations to the known disabilities of individuals in compliance with the Americans with Disabilities Act. For accommodation information or if you need special accommodations to complete the application process, please contact Patricia Gilliam, RSVP Director at (336) 269-2762.
For Questions Contact:

Mr. Jeremy Sumpter, Sr.

RSVP Director

RSVP Phone: 336-757-6288

Email: jaysumpter@lovecdcrsvp.org
For Questions Contact:

Patricia Gilliam

RSVP Program Assistant

Mobile: 336-269-2762

Email: pgilliam@lovecdcrsvp.org
The following information is optional and will not affect your enrollment with Love CDC RSVP
LoveCDC RSVP provides AmeriCorps Seniors t-shirts for their volunteers. Please select from the following sizes:

SMLXL1X2X3X4X5X
RSVP is often asked to provide demographical information pertaining to volunteer members. Please provide the following information (Optional).
Are you a Veteran?

YesNo
Are you an active Military Member?

YesNo
Are any of your family members actively serving in the military?
Gender

MaleFemaleOther
Race/Ethnic Background

WhiteAsianAfrican AmericanHispanic/LatinoAmerican Indian/Alaska NativePacific IslanderOther
Thank you for any information you have provided. Your information is never sold, shared, or used outside of Love CDC RSVP or the Corporation of National and Community Services.
Should be Empty:

(Retired and Senior Volunteer Program)

Sponsor/Grantee

Volunteer Enrollment Form

Please complete all sections. Forms with original signatures are required for enrollment.

Driver's License

Emergency Contact Information

Volunteer Matching Information

Likeness

Certifications

The following information is optional and will not affect your enrollment with Love CDC RSVP