Community Services

Today's Date:

Name:

Email Address:

Birth Date::

Address:

City:

Zip:

Home Phone:

Cell Phone:

Physical/Medical Limitations:

How did you hear about RSVP?

I understand that every new volunteer will require a PA State Criminal History clearance before any placement is made. This ensures and maximizes the safety of volunteers and the clients served. I give my permission for such clearances to occur, or will provide my own. To obtain your own free volunteer background check, please go to: https://epatch.state.pa.us/Home.jsp. Please bring a copy of your certification to your volunteer orientation appointment.

Have you ever been convicted of a felony? YesNo

Name:

Phone #:

Relationship:

Check if same as Emergency Contact

Name:

Phone #:

Relationship:

Address:

Race/Ethnic Background:

African American/Black

Asian/Asian American

Hispanic/Latino

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Two or more races

White/Caucasian

Delivering Meals on Wheels
Assist at Food Pantry
Assist at a Senior Center
Ombudsman
American Red Cross
Friendly Caller
Pike County Hands of Hope
PA Medi Medicare Insurance Counseling
Ladore Camp, Retreat & Conference Center

Salvation Army Honesdale Extension Berks Encore
Colebrookdale Railroad
Brandywine Library
Boyertown Area Multi-Service
Junior Achievement of SEPA
Miller Keystone Blood Center
Helping Harvest

Active Volunteers, On Leave, Background Checks, Confidentiality, Volunteer Safety Policy, Use of Automobile, Photography Waiver, Code of Conduct, Drug Free Workplace Policy.

I have read, understand, and agree to the above volunteer policies and certifications in the Volunteer Handbook.

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Diakon does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, creed, religion, sex,
national origin, sexual orientation, age, marital status, veteran status, disability or any other classes protected by law.

Volunteer Enrollment Form RSVP of Berks, Pike and Wayne Counties

Volunteer Clearances Agreement

Emergency Contact

Beneficiary for Supplemental Volunteer Accident Insurance

RSVP is often asked to provide demographical information pertaining to volunteers

Please check your area(s) of interest in serving

Please check your availability

Interests/Hobbies/Work Experience/Volunteer Experience

If currently volunteering, please provide location

Volunteer Handbook Policies, Agreements and Certifications