Generations Volunteer Enrollment Form
A program of Vincennes University, Generations is the Area 13 Agency on Aging & Disability PO Box 314

1019 N. 4th Street Vincennes, IN 47591

Email: catherine.jones@vinu.edu

Phone:  812-888-5159

Generations Toll Free: 1-800-742-9002

Fax: 812-888-4566

** A parent's/guardian's permission is required for students under the age of 18 **
Name
Address
City
Street
Zip Code
Age
Date of Birth
MM
/
DD
/
YYYY
Have you served in the military?
Clear selection
Are you a Student? *
If you are a student, what school did you attend?
I give permission for this student under age 18 to volunteer:
Parent Phone Number
Parent (Guardian) Name
Telephone Number
2nd Phone Number
Email Address
Emergency Contact
Relationship
Emergency Telephone Number
Emergency Contact's Address
List any limitations or special accommodations which would need to be considered for your placement:
Please list a reference (name, address, and telephone number):
Release of Information
I give Generations permission to release my picture and information for news releases
Signature of Volunteer
Date of Signature
MM
/
DD
/
YYYY
Do you drive your own car?
If you drive your own car to volunteer assignments, you are covered by insurance in excess of your own insurance. You are also covered for personal injury (accidental) occurring during your volunteer activities. This is a benefit and at no cost to you.
Clear selection
Driver's License Number
Expiration Date
MM
/
DD
/
YYYY
Beneficiary for Secondary Accident Insurance
(can indicate estate or an individual)
Beneficiary Relationship
Beneficiary Address
Volunteer Signature
Volunteer Interest Checklist
Please check all areas of interest. This will help us match your interest with the various volunteer opportunities. Orientation and training will be provided for all volunteer services.
Referred for school assignment: please list
Volunteer Agreement
Thank you for your interest in Generations’ volunteer program. 

Please review and sign. 

If accepted into the Generations’ volunteer program, I agree to: 
  1.  Authorize Generations volunteer staff to complete a limited criminal background check through a local or state law enforcement agency. 
  2. Hold all information confidential that I may obtain directly or indirectly concerning VIP’s, nursing facilities and staff - and not seek to obtain confidential information from a VIP, if assigned to AngelWorx. 
  3. Abide by the policies and procedures of the program and uphold its philosophies and standards. 
  4. Donate my services to the program without contemplation of compensation or future employment. 
  5. Be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality. 
  6. Carry out assignments and seek the assistance of Generations volunteer staff when necessary. 
  7. Take any problems, criticisms or suggestions to the Generations volunteer staff. 
  8. Contact my assigned VIP or Nursing facility at least twice a month by letter, phone call and/or visit, if assigned to AngelWorx. 
  9. Report my volunteer time to Generations volunteer staff by the 5th of each month by email, phone call or mail. 
  10. Report all accidents to the Generations volunteer staff immediately.
Volunteer Signature Agreement
I have received and read the above conditions which I agree to follow.
Math CAPTCHA: 1800 + 1 =  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Vincennes University.

Does this form look suspicious? Report

Google Forms