rsvp logoVolunteer Registration Form
RETIRED AND SENIOR VOLUNTEER PROGRAM
627 N. Glenstone, Springfield MO  65802 
Phone (417)862-3595  -  Fax (417)862-2129
eMail:  sbradford@ccozarks.org  or bbullock@ccozarks.org 
Please complete all parts of this form and mail to address above.
All information is solely for RSVP office use and remains strictly confidential.
Name:      Are you a past member of RSVP?  Y  N

Mailing Address:   Street   City   Zip Code
Telephone Numbers:  Home   Cell   Other
eMail Address:   

Birthdate:  Month   Day   Year   Gender: Male Female
Spouse's Name:  Aniversary: Month Day Year

Driver's License Number
If you do not drive, what form of transportation do you use? 
Will you need RSVP Van transportation?  Yes  No

Physical Limitations: 

Ethnicity:  American Indian?Alaskan  Asian/Pacific Islander  African American
                 Hispanic White

Previous Occupation and Employer: 
Educational Background: 
How did you hear about RSVP? (if from a friend, please tell us their name):

All RSVP members receive FREE accident insurance. 
Who would you like to designate as your beneficiary?

Name:  Relationship:   Phone:

Please list two (2) LOCAL persons we should call in the event of an emergency:
Name:   Relationship:    Phone: 
Name:   Relationship:   Phone:

Current civic/community/volunteer involvement:
The following information will be used to match you with volunteer opportunities.  Please check as many that are of interest as you like, but ONLY those in which you are willing to serve as a volunteer.

 Administrative/Management Entertainment Mobile Meals
Arts/Crafts Environment Nursing Homes
At-Risk Youth Food/Clothing Bank Receptionist
Bulk Mail/Zip Coding Food & Nutrition Reading Buddy
Child Advocacy Friendly Visitation Senior Advocacy
Children Fundraising Senior Centers
Clerical/Office Gardening Serve as Board Member
Companionship/Outreach Gift Shops   Sewing
Computers Homebound Shopper   Stuff/Label (Group)
Consumer Protection Hospice/Terminally Ill   Tax Assistance
Cook/Serve Meals Hospital/Medical   Telephoning (senior shut-ins)
Crime Prevention Information Desk   Telephoning (office)
Data Entry Knitting/Crocheting   Theatre/Fine Arts
Disaster Relief/Preparation Literacy/Tutoring   Tutoring Adults
  Docent Mentoring   Van Drivers
Other (please specify: 

Your special talents/skills: 

Anything else you would like us to know about you?


This is authorization to use your image in any publication RSVP may use for promotion or otherwise.  YES  NO   

x Signature:    Date: