RSVP Volunteer Application RSVP Application Please fill out this form in entirety to apply as a volunteer to RSVP. Your Personal InformationYour Name(Required) First Last Birth Date(Required)Your Email Address(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Home Phone(Required)Cell Phone(Required)Best Time To Call You(Required)When is the best time for us to reach you via telephone?MorningsEarly AfternoonLate AfternoonEarly EveningAre you a Veteran?(Required)YesNoHave you ever been convicted of a criminal offense or misdemeanor?(Required)YesNoIf 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.Max. file size: 20 MB.Please list any Physical/Medical Limitations here:(Required)Driver's License #(Required)State(Required)Expiration Date(Required) MM slash DD slash YYYY RSVP provides a mileage reimbursement for travel between home and volunteer site to the volunteers. Will you be claiming a mileage reimbursement for travel to and from your volunteer location?(Required)YesNoIf Yes, please provide proof of auto insurance showing active coverage here.Max. file size: 20 MB.As a volunteer of RSVP, you will be covered by accident, personal liability, and excess automobile 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 RSVP.Please provide the name and phone number of your Emergency Contact:(Required)Beneficiary for RSVP Supplemental Accident Insurance:Name(Required)Address(Required)Relationship(Required)Phone Number(Required)Tell us more about you…Please describe your employment experience here:(Required)Please describe any special skills, interests, or languages you are able to speak/understand:(Required)Please describe any past or current volunteer experience:(Required)Hours You Are Available to Volunteer(Required)Please tell us what hours you are available to Volunteer.MondayTuesdayWednesdayThursdayFriday Add RemovePlease indicate if RSVP may have permission to use your likeness?(Required) I hereby grant RSVP of Lackawanna, Luzerne and Wyoming Counties 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 RSVP of Lackawanna, Luzerne and Wyoming Counties in perpetuity. I will make no monetary or other claim against RSVP of Lackawanna, Luzerne and Wyoming Counties for the use of these photograph(s)/video(s). I do not give permission to use my likeness in photograph(s)/video(s) to RSVP. CertificationsBy 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 Lackawanna, Luzerne and Wyoming Counties Retired and Senior Volunteer Program. I understand that I am not an employee of the RSVP Project, United Way of Lackawanna & Wayne Co., Lackawanna County, 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 Pennsylvania. I will also keep in effect a valid Pennsylvania Driver’s license.RSVP Volunteer Signature(Required)Date(Required)Equal Employment AgencyRSVP 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 RSVP of Lackawanna, Luzerne and Wyoming Counties at (570)-343-1267.RSVP is often asked to provide demographical information pertaining to volunteer members. Please provide the following information (Optional).Are you a Veteran?YesNoAre you an active Military Member?YesNoAre any of your family members actively serving in the military?YesNoGender (Optional): Male Female Race/Ethnic Background (Optional): White Asian African-American Hispanic/Latino American Indian/Alaska Native Pacific Islander Other Thank you for any information you have provided. Your information is never sold, shared, or used outside of RSVP of Lackawanna, Luzerne and Wyoming Counties or the Corporation of National and Community Service.