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Mayflower Retired & Senior Volunteer Program
385 Court Street, #104, Plymouth, MA 02360
Tel: 508-746-7787 Fax: 508-746-7795
[email protected]
RSVP VOLUNTEER REGISTRATION
Name: ___________________________________ Date of Birth (MUST BE 55 or older): _______________
Mailing Address: ___________________________________________________________________________
Email Address: __________________________________ Tel #(s): __________________________________
Please note that the federal agency that oversees us, the Corporation for National & Community Service ,
requires that you
provide a photocopy of a photo I.D., such as driver’s license, showing date of birth.
Emergency Contact: _________________________________ Relationship: ____________________________
Address & Phone: __________________________________________________________________________
Other than self, Beneficiary of Free RSVP Insurance: ______________________________________________
Address & Phone: __________________________________________________________________________
Work Experience/Education: __________________________________________________________________
__________________________________________________________________________________________
Volunteer Experience: _______________________________________________________________________
How did you hear about us? ______________________________________ Are you a veteran? ____________
I hereby give permission for photos or videos of my service activity to be used to promote senior volunteers.
________________________________________________________________________________________
Volunteer Signature
Date
I understand that I am not an employee of National Senior Corps/RSVP or Mayflower RSVP. If I use my vehicle while
volunteering, I will maintain a current driver’s license and automobile liability insurance at least equal to that required by
the Commonwealth of Massachusetts. I understand that I am expected to be free from the influence of alcohol or illegal drugs
while volunteering. I understand that a National Sex Offender Public Website (NSOPW) search will be conducted prior to
my serving in a volunteer capacity, and that a Massachusetts Criminal Offender Registry Information (CORI) request may
be performed by the service partner agency prior to my serving in a volunteer capacity.
________________________________________________________________________________________
Volunteer Signature
Date
________________________________________________________________________________________
RSVP Outreach Coordinator
Date
________________________________________________________________________________________
RSVP Director
Date