Volunteer Application Form
1025 Main, #D114
Great Bend, KS 67530
Office: (620) 792-1614
Fax: (620) 793-7689
E-mail: volunteersinaction@bartonccc.edu

Thank you registering as a volunteer for Volunteers In Action. Your volunteerism is enhancing the lives of those in our community. We are interested in YOU and what is meaningful to YOU. What skills do you possess that could help an agency in need? Please be as thorough as you can so that we can place you with the volunteer opportunities best suited for you.

RSVP
Personal Information
First and Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Example: KS
Your answer
Zip Code *
Your answer
Primary Telephone *
Example: 123-456-7890
Your answer
Birthdate *
Type in the date below or select it from the calendar.
MM
/
DD
/
YYYY
Email Address
Your answer
What is the best method of contact? *
Please select all that apply.
Required
Please select all that apply to you:
This data is for statistical analysis with respect to the success of the Affirmative Action program.
If Retired, where from?
Your answer
Position?
Your answer
Referred to VIA/RSVP by:
Your answer
Are you currently volunteering?
If so, where?
Your answer
Days available to volunteer: *
Slect all that apply.
Required
Time available to volunteer: *
Slect all that apply.
Required
Emergency Contact *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone Number *
Please include area code.
Your answer
Areas of Interest
Selecting an area doesn't obligate you. Select all that apply in each section below.
Community Service
Hospitals
Nursing Homes
Special Projects
Clerical
General Maintenance
Hunger Relief
Beneficiary for VIA/RSVP Insurance
Name *
Not your name, use next of kin, spouse, child, etc.
Your answer
Relationship *
Your answer
Address *
Your answer
City, State and Zip Code *
Your answer
I will volunteer my services through the VIA/RSVP Program and understand that I am not an employee of the Barton Community College. I understand that if I use my personal automobile in my volunteer service, I will arrange to keep in effect automobile liability insurance equal to the minimum limits required by the state of Kansas. I will not conduct or engage in religious, sectarian, or political activities during volunteer hours with VIA/RSVP. I release VIA/RSVP and Barton Community College, their trustees, directors, agents and employees, from any liability, claims and demands, whether known or unknown, arising out of the participation by the undersigned in the Volunteers in Action. I further agree to indemnity and hold harmless the VIA/RSVP and Barton Community College, their trustees, directors, agents and employees, from any such liability, claims and demands. I hearby grant VIA/RSVP permission to use my likeness in photograph(s) video in any and all of its pulications or on the worldwide web, whether now known or hereafter existing, controlled by VIA/RSVP in perpetuity. I will make no monetary or other claim against VIA/RSVP for the use of the photograph(s)/video. *
By signing this form I authorize VIA/RSVP to use my electronic signature below as authorization to process this volunteer registration form.
Your answer
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