VOLUNTEER ENROLLMENT FORM

Insurance Information
Driver's Liscence Number
State
Auto Insurance Company
Phone Number
Please enter a valid phone number.
Volunteers for Volunteer Transportation Program must have auto liability insurance equal to or greater to: Property Damage Liability $50,000/Bodily Injury Liability $100,000/$300,000 Liability per occurrence. Do you currently have this coverage?

YesNo
For all other programs, insurance coverage must meet the minimum limits required by the State of Wisconsin: Property Damage Liability $10,000/ Bodily Injury Liability $25,000 per person. Do you currently have this coverage?

YesNo
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.

All volunteers are covered by a supplemental personal liability, accident and auto liability insurance policy during the entire time spent volunteering (to, during, and from an assignment). Please designate a beneficiary.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship

Volunteer Agreement
I will adhere to all relevant policies of Kenosha Area Family and Aging Services, Inc. (KAFASI) and to the highest standards of conduct and confidentiality. As a volunteer with KAFASI, I understand that I may interact with people of diverse socioeconomic, ethnic, religious, and age backgrounds; I will not discriminate against them. I understand that KAFASI may conduct a criminal background check with the Wisconsin Department of Justice and a national sex offender background check and that information obtained will not automatically disqualify me from consideration. I understand that all information on this form will be kept strictly confidential. I also understand that KAFASI, the program/individual with whom I volunteer, or I may terminate my volunteer service at any time. In addition, I have no objection to the use of my photograph/video by KAFASI for the specific purpose of publicity, public relations or educational promotion, providing it is legitimately published with discretion, and I give consent for these purposes. I understand that information may be shared in order to ensure programmatic compliance, however, information is never sold or shared with external parties.
Volunteer Signature*

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KAFASI Staff Signature

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Afternoons (Noon - 4pm)

General Information