DELAWARE HEALTH
AND SOCIAL SERVICES
Sussex Retired and Senior Volunteer Program
State Office of Volunteerism
Division of State Service Centers
546 S. Bedford Street
Georgetown De  19947
Ph.# 302-856-5816  Fax # 302-856-5255


Volunteer Enrollment Form

Please print and complete all sections.

Volunteer Site 

Name					Birth Date		Phone
Address
City				State		Zip		Social Security# 

Ethnic group:	Caucasian	African-American	Hispanic	Asian, Pacific Islander
		Native American/Alaskan Native		Other

Physical Limitations

Do you have a car?	Yes	No		Claiming mileage reimbursement?	Yes	No
Driver’s license #				State			Exp. Date
Emergency Contact							Phone

Beneficiary for RSVP Supplemental Accident Insurance:
Name								Relationship 
Address								Phone

Previous Occupation	 
Skills/Interests/Languages 
Volunteer Experience 
Day/Hours Available 

I understand that if I use my personal automobile to and from my volunteer workstation,
I will arrange to keep in effect automobile liability insurance equal to or greater
that the minimum required by the state.


How did you hear about RSVP?  (Circle all that apply)

		Friend					Brochure/Poster

		Newspaper				Community Agency

		Radio/TV Ad				Other: 



		
	Signature of Volunteer					Date


		
	Signature of RSVP Staff					Date



FOR OFFICE USE ONLY!

Signature of RSVP Director

Station (s) assigned 

Date Assigned 

Welcome Package Sent 

Entered in Computer/Reporter				By: