Volunteer Registration Form

Thank You!

If you are interested in volunteering, please complete this form and our Volunteer Coordinator will reach out to you. Thanks for your interest!

Name*
Prefix First Last
Personal Pronouns (ex: she/her, they/them, he/his)
Address*
Street Address Address Line 2 City State ZIP Code
County*
Email*
Phone*
Date of Birth*
Month
Day
Year
Are you over 55*
- Yes
- No
Are you interested in joining our RSVP Program?*
Congratulations! You qualify for our RSVP program, part of the nationwide AmeriCorps Seniors initiative. Many of our volunteers opportunities are also RSVP placements, and by signing up you help us share the impact people age 55+ are having in our community. RSVP also provides additional perks, including special recognition and covering the cost of your volunteer background check!
- Yes, sign me up!
- No
Are you a veteran?*
- Yes
- No
If yes, which branch?
Are you a college student?*
- Yes
- No
Do you need a certain # of hours of volunteer service?*
- Yes
- No
What days are you available?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
What volunteer opportunity(s) are you interested in?*
- Deliver Meals (Meals on Wheels)
- Deliver Groceries (Take Out Tuesday/Senior Staples))
- Teach Classes (Center for Active Living)
- Benefits Counseling (SHIP)
- Lead Classes (ADH)
- Visit Nursing Home Residents (LTCO)
- Help in Our Garden
- I'm not sure yet
What size shirt do you wear?
- Small
- Medium
- Large
- XL
- 2XL
COVID-19 Safety Information*
To provide the safest environment for everyone, individuals participating in ACCA activities must certify the following by checking each box:
- I understand the COVID-19 symptoms: Fever and chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; New loss of taste or smell; Sore throat; Nausea or vomiting; Diarrhea
- I will immediately inform ACCA and discontinue volunteering if I, or any member of my household, develops any symptoms of COVID-19.
- I will immediately inform ACCA and discontinue volunteering if I, or any member of my household tests positive for COVID-19.
What is your COVID-19 vaccination status?*
ACCA follows CDC definitions regarding vaccination status.
- Fully Vaccinated
- Not Fully Vaccinated
Any person who is participating in an ACCA activity and/or enters an ACCA premise, waives all civil liability against this premises owner/operator for any injuries caused by the inherent risk associated with contracting COVID-19 at public gatherings, except for gross negligence, willful and wanton misconduct, reckless infliction of harm, or intentional infliction of harm, by the individual or entity of the premises.*
- I understand and certify the above policy
Why are you interested in volunteering with ACCA?*
How did you hear about volunteering with ACCA?*
Emergency Contact
Name*
First Last
Phone*
Emergency Information
Hospital Preference
Preferred Physician
Medical Conditions
Allergies
Driving Info
Will you be driving your car as a volunteer?*
Volunteers in the following programs will likely be driving their personal car during volunteer service: Meals on Wheels, Take Out Tuesday, SHIP, & LTCO. If you will only be driving your car to and from service at ACCA, you can check "No".
- Yes
- No
Drivers License #*
State*
Expiration Date*
MM slash DD slash YYYY
Volunteer Policy Agreements*
By checking the boxes, you (the volunteer) are confirming that you understand and will abide by these policies.
- I understand that if I use my personal automobile in my volunteer service, I will arrange to keep liability insurance equal to the following minimum amounts: $25,000 each person and $50,000 each occurrence for bodily injury, and $25,000 each occurrence for property damage
- I understand that I will receive orientation and training materials from ACCA, and that I am responsible for reading these materials and abiding by the training.
Statement of Conduct Acknowledgement*
By checking this box you are confirming that this is true.
- I have never been shown by credible evidence to have abused, neglected, or exploited any person.
Connections Magazine
We want to keep you updated on everything happening at ACCA. Would you like to receive our quarterly magazine?
- Yes, mail me a printed version
- Yes, send me an electronic version
- No

Exit mobile version

Thank You!

Emergency Contact

Emergency Information

Driving Info