Name (First, middle, last) *

Address *

Phone number *

Email

Date of birth *

Gender *

Marital Status *

Emergency Contact #1 - Name and relationship *

Emergency Contact #1 - Phone Number *

Emergency Contact #2 - Name and relationship

Emergency Contact #2 - Phone Number

Other names previously used (including previous married names/maiden names) *

Physical limitations: *

Are you currently volunteering anywhere in Otsego County? If so, where? *

Are there specific agencies you are interested in volunteering for? *

I agree that if I use my personal vehicle for volunteer services, I will maintain a current, valid drivers license as well as vehicle insurance equal to or greater than the minimum limit required by the State of Michigan *

The information requested in the next two questions are for statistical purposes as requested by various federal and state funding sources. Provisions of this information is voluntary and will be available to authorized personnel only. Are you handicapped?

Race (check all that apply) *

CONSENT AND CONFIDENTIALITY STATEMENT: I volunteer my services through Otsego County United Way. I understand that I am not an employee of the agency. I hereby agree to regard all information received in the performance of my volunteer work as confidential. I further agree to respect individual rights to privacy, as well as those of the person, family and/or volunteer station for whom I am volunteering. I understand that the volunteer station will respect my rights regarding privacy of information. The volunteer station agrees to respect those rights in the performance of my volunteer duties and keep professional confidentiality in all my statements both inside and outside the station.I hereby grant permission for The Otsego County United Way to check with the appropriate authorities upon matters of record regarding my background and history as they relate to be a volunteer. 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 or greater than the minimum limits required by the State of Michigan.I agree to all the terms of this Volunteer Registration Form. I understand that all the information provided/obtained in this registration will be kept strictly confidential. * *

By typing your full name into this box you are consenting to a digital signature and verifying that you have read the above information. *

Volunteer Interest Checklist (select all you might be interested in) *