Volunteer Registration Form

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Your Personal Information

Your Name*

First Last

Preferred Pronouns (ex: she/her, they/them, he/his)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Email Address*

Enter Email Confirm Email

Your Phone*

Date of Birth*

Are you over 55?*

Yes

Are you a veteran?*

Yes

Are you volunteering as part of a group (i.e. through a school)?*

Yes

Are you a college student?*

Yes

Because of logistics related to onboarding, training, and client protection, volunteers must volunteer for at least a year. I acknowledge this and can meet this requirement.*

Yes

What days are you available?*

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday/Sunday (only)

What volunteer opportunity(s) are you interested in?*

Delivering meals (Meals on Wheels)

Deliver Groceries (Take Out Tuesday/Senior Staples)

Teach Classes (Active Living)

Benefits Counseling (Medicare/SHIP)

Lead Classes (Adult Day Health)

Visit Nursing Home Residents (Long Term Care Ombudsman)

Work in the Garden

I'm not sure yet

What size t-shirt do you wear?*

Small

Medium

Large

2XL

3XL

Background Check Fee Acknowledgement*

Because we work with a vulnerable population, most volunteer roles at ACCA require a background check. If possible, we ask volunteers to help pay part of this cost. The fee we ask volunteers to pay is $35, if you are unable to do this, we can provide a waiver. RSVP (folks 55+) volunteers do not have to pay.

I am able to pay the $35 fee

I am unable to pay the $35 fee

Special Skills and Qualifications*

Emergency Contact*

First Last

Phone*

Hospital Preference

Physician Preference

Medical Conditions

Allergies

Policy and Insurance Acknowledgements

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".

Full-Time

Part-Time

Temporary

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*

I have never been shown by credible evidence to have abused, neglected, or exploited any person.

By checking this box you are confirming that this is true.

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