Form Center

2. 

4. This enrollment application is for volunteers age 55 and above. Please complete all sections.

6. First Name*
7. Last Name*
8. Preferred / Nickname
10. Street Address
12. Address Line 2
14. City
15. State
16. Zip Code
18. Phone*
19. Cell Phone
21. Email
22. Date of Birth*
    Date of Birth
26. Physical / Medical Limitations
28. Employment Experience
30. Special Skills / Interests / Languages
32. Volunteer Experience (Current, Past)
34. Preferred Volunteer Opportunity / Station / Location (if known)
36. How did you hear about RSVP?*

38. As a RSVP volunteer, 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 RSVP. Please provide the following information:

40. Emergency Contact - First Name
41. Last Name
42. Relationship
43. Phone Number
45. Beneficiary for RSVP Supplemental Accident Insurance - First Name
46. Last Name
47. Relationship
49. Street Address
51. Address Line 2
53. City
54. State / Province / Region
55. ZIP / Postal Code
57. Country
58. Phone Number
62. Morning Availability

    1. Monday Morning
    2. Tuesday Morning
    3. Wednesday Morning
    4. Thursday Morning
    5. Friday Morning
    6. Saturday Morning
    7. Sunday Morning
63. Afternoon Availability

    1. Monday Afternoon
    2. Tuesday Afternoon
    3. Wednesday Afternoon
    4. Thursday Afternoon
    5. Friday Afternoon
    6. Saturday Afternoon
    7. Sunday Afternoon

65. The following information is optional and will not affect your enrollment with NHC RSVP.

67. Gender

    1. Male
    2. Female
    3. Nonbinary
68. Race / Ethnicity
70. Marital Status

    1. Single
    2. Married
    3. Divorced
    4. Widowed
71. Military

    1. Active
    2. Veteran
    3. None
72. Are any of your family members actively serving in the military?

    1. Yes
    2. No
74. More Info

    Please feel free to provide any additional information that might help us learn more about you, so that we can match you to the best volunteer opportunity.

78. Volunteer Agreement

    By checking "I Agree", 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 New Hanover County Retired Senior Volunteer Program. I understand that I am not an employee of the RSVP Project, the sponsor, New Hanover 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 as an RSVP Volunteer I must maintain regular communication, including signing in to track volunteer hours, with my volunteer station and/or coordinator. I understand that I must participate in a New Volunteer Orientation prior to choosing, and starting at any site. It is my responsibility to complete the volunteer application and orientation process with the RSVP team at the Senior Center. I also understand that I must complete any training at my volunteer station(s) that is required.

    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.

    As an RSVP Volunteer I have a right to meaningful work at the available volunteer station of my choice. I understand that at the chosen station I must represent myself, the New Hanover County Senior Resource Center, The New Hanover County RSVP Project and my volunteer station in a professional manner. I understand that by signing this enrollment document I agree to review the volunteer assignment responsibilities for the station(s) of my choice, located in the Volunteer Program Handbook and agree to uphold my job assignment. I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.

80. Volunteer Agreement*

    1. I agree
82. Equal Employment Agency

    New Hanover County RSVP is an equal opportunity Agency. Enrollment is done without regard to race, color, national origin, gender, sexual orientation, religion, age, disability, political affiliation, marital or parental status, or military service. AmeriCorps Seniors 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 New Hanover County RSVP at 910-798-6406.

    Thank you for the information you have provided. Your information is never sold, shared, or used outside of RSVP and New Hanover County.

    For questions contact:

    Becky Doherty
    RSVP Program Coordinator
    Phone: 910-798-6406
    Email Becky Doherty

84. Confidentiality Policy

    The New Hanover County Senior Resource Center policy regarding confidentiality of citizen information is in accordance with laws which specifically address confidentiality (GS 130A-12, GS 130A-143, GS130A-212). All information concerning citizens is strictly confidential and should only be discussed or shared:

    • With those specifically authorized by written consent of the citizen, or others authorized to give consent for the citizen;
    • When necessary to provide appropriate care (within our agency) except as described in GS 130A-143;
    • Pursuant to subpoena or court order.

    Failure to observe the policy regarding confidentiality is reason for suspension or dismissal and may subject the employee, student, volunteer or contract worker to a lawsuit. All employees, students, volunteers, and contract workers will be required to sign a statement of understanding regarding this policy.

    • I understand that I may have direct or indirect access to confidential individually identifiable personal information (IIPI) in the course of performing my work activities.
      • Note: IIPI is any information collected from an individual that is created or received by the NHCSRC and relates to past, present or future contact, beneficiary, or individually identifiable information. Protected personal information (PPI) is IIPI in any form: paper, oral or electronic, that personally identifies an individual.
    • I agree to protect the confidential nature of all IIPI to which I have access and will not divulge this information to unauthorized persons.
    • I understand that there are state and federal laws and regulations that ensure the confidentiality of an individual’s identifying personal information.
    • I understand that there are New Hanover County Senior Resource Center (NHCSRC) policies and procedures with which I am required to comply related to the protection of IIPI.
    • I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.
    • I understand how I am expected to ensure the protection of IIPI. Should questions arise in the future about how to protect information to which I have access, I will immediately notify my supervisor and/or the NHCSRC Director.
    • I have been informed that this signed agreement will be retained on file for future reference.
86. Confidentiality Policy*

    1. I agree to this confidentiality agreement.
88. General Photo Release

    I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to publish photographs taken of me, as well as my name and likeness, for use in the NHCSRC’s print, online and video-based marketing materials, as well as other Company publications.

    I hereby release and hold harmless NHCSRC from any reasonable expectation of privacy or confidentiality associated with the images specified above.

    I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

    I hereby release NHCSRC, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.

90. General Photo Release*

    1. Consent
    2. Decline

    You may either consent to or decline to release your photo rights as described above.

92. General Communication

    I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to contact me at the phone number(s) provided via SMS (text) message and communicate with me regarding volunteer duties, responsibilities, scheduling, and availability. I hereby release and hold harmless NHCSRC from any expectation of privacy or confidentiality associated with this communication. I understand that I can opt out from receiving text messages by texting ‘STOP’ as a reply. I further acknowledge normal cellular data and messaging rates may apply. The number of SMS (text) messages received will be limited and will generally not exceed more than 5 messages a month.

     

94. General SMS Message Acknowledgment Release*

    1. Consent
    2. Decline

    You may either consent to or decline to allow SMS (text) messaging as described above.

96. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
98. Electronic Signature*

100. Thank you for your interest in volunteering with New Hanover County RSVP (Retired & Senior Volunteer Program). We will be in touch soon!

Leave This Blank:


103. 1. Receive an email copy of this form.
104. Email address

     This field is not part of the form submission.

105. Submit

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