Volunteer Application

 RIVERSIDE COUNTY OFFICE ON AGING VOLUNTEER SYSTEMS

 CONFIDENTIAL INFORMATION--

DISCLAIMER

Riverside County Ordinance 440, as amended, states in Section IC. IF County insurance: Such liability insurance as the County May carry shall be excess insurance over any other valid collectible insurance, including that provided by the volunteer worker.

Volunteer workers are not covered by workers compensation insurance or by county self-insurance for injury or accident arising out of volunteer service.

I have read and understand the foregoing notice. In addition, I understand that as a volunteer for the Riverside County Office an Aging I will not accept gifts or services from those I serve as a result of the, performance of my duties as a volunteer. I further understand all information I obtain from those I serve is of a confidential nature and is not to be divulged outside the confines of the Agency, As well, I understand the Office on Aging has the right to accept my services as a volunteer or to revoke them at any time.

_____________________________________          ___________________________________________

Volunteer's Signature                                                           Date

Name: ______________________________________________________________________________________

Address: ___________________________________________________________________________________

City: ____________________________________ State: ___________ Zip Code: _____________

Phone: (___)______-___________ E-Mail Address: ____________________________________

Date of Birth: _____/_____/___________   Gender:  Male_____      Female______

Emergency Contact: _________________________________________________

Phone: (___)______-___________ Relationship: ________________________________

Address: _______________________________________________________________

City: ____________________________________ State: ___________ Zip Code: ____________

SKILLS & INTERESTS

(please check all that apply)

_____Accounting/Bookkeeping                  _____Administration Assistance                         

_____Advocacy                                            _____Arts & Crafts Instruction                                          

_____Computer Skills                                   ______Construction                                                               

_____Driving                                                 ______Senior Care

_____Serving Special Needs People          ______Social Service/Counseling

_____Special Events                                    ______Tax Preparation

_____Teaching                                             ______Visitor Services

_____Food Preparation                               ______Food Programs                                                       

_____Fundraising                                         ______Host/Hostess                                                                        

_____Insurance (Health)                             ______Legal/Aid Assistance

_____Medical/Health Aide                         ______Office / Clerical

_____Phone Support                                    ______Planning and Needs Assessment

_____Reading to Others                              _____OTHER (pleae list below)