ADRC Volunteer Application

ADRC Volunteer Application

Volunteer Primary Information

Name*

Address*

Enter street address, city, state and zip code

Email*

Date of Birth*

Primary Phone Number*

Phone

Secondary Phone Number

Phone

Emergency Information

Note: In the event of an accident or illness while serving the Racine County Senior Nutrition Program, the person listed below will be called if necessary. In an emergency, the Rescue Squad will be called.

Name*

Relationship*

Address*

Enter street address, city, state and zip code

Primary Phone Number*

Phone

Secondary Phone Number

Phone

Volunteer Information

Are you applying to fulfill any school or church requirements?*

Yes

Affiliation:*

Please provide more information on the school or church affiliation.

How many hours do you need to complete?*

Date of Completion*

Are you applying for community service hours?*

Yes

Please briefly describe the nature of your offence.*

How often are you available to volunteer?*

Weekly

Bi-Weekly

Once a Month

Describe any prior volunteer experience*

Preferred Program*

Meals on Wheels

Senior Nutrition Program

Volunteer Guardian

Other (Please Specify)

Preferred Program (Specify)*

What is your preferred volunteer program?

Company Volunteer Team

Company Volunteer Team*

Are you applying as a part of a company volunteer team?

Yes

Company Name*

Company Address*

Enter street address, city, state and zip code

Company Phone*

Phone

References

Please list two references (no close relatives) that we may contact.

Reference Name 1*

Reference Phone Number 1*

Phone

Reference Name 2*

Reference Phone Number 2*

Phone

By checking this box, I agree this is an electronic representation of my signature - just the same as a pen-and-paper signature.

Signature Authorization*

Parent/guardian of minor (under the age of 18 years)

By checking this box, I agree this is an electronic representation of my signature - just the same as a pen-and-paper signature.

Parent/Guardian Signature Authorization

Required Background Check

A background check is required to volunteer for Aging and Disability Resource Center Programs. Please complete background check with the link provided and email signed copy to RCNutrition@racinecounty.com

https://www.dhs.wisconsin.gov/forms/f8/f82064.pdf

Meals on Wheels

This section must be completed if you are applying for Meals on Wheels.

Driver's License and Insurance Verification

The Aging and Disability Resource Center of Racine County assumes no responsibility for providing automobile insurance for volunteer drivers. It is the volunteer’s responsibility to provide automobile insurance and have a valid driver’s license while delivering meals for the Racine County Senior Nutrition Program.

Driver's License Number*

Expiration Date*

Please provide a copy of your insurance card with your application.*

Drag and drop files here or

Have you had any traffic violations within the past 5 years?*

Yes

As part of being a Meals on Wheels volunteer, we will have you sign a Vehicle Use Agreement. As part of this information, we require the last 4 digits of your SSN.*

Please provide the last 4 digits of your SSN.

For more information or questions/concerns, please contact:

RCNutrition@racinecounty.com or (262) 833-8766

NOTE: After you click 'submit' on this form, you will receive a confirmation email within 10 minutes of your submission.

Send me a copy of my responses

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