Adult Volunteer Application "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Personal InformationName* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(s)* Home Cell Home PhoneCellphoneEmail Address* Your Social Security Number (for background check). This information is kept confidential.*Birth date (for background check)* MM slash DD slash YYYY Are you currently a member of Surrey?* Yes No This field is hidden when viewing the formYour Social Security Number (for background check). This information is kept confidential. Numbers only no dashes.*How did you learn about our volunteer opportunities?*Where are you most interested in volunteering? Broomall Bryn Mawr Devon Media Other Have you ever been convicted of a felony or misdemeanor?* Yes No AuthorizationI, hereby grant permission for a duly authorized representative of Surrey Services for Seniors to conduct information checks for my background. Type your name to sign*Date* MM slash DD slash YYYY Emergency ContactThank you for your Volunteer Application. Surrey will use the information provided below for the express purpose of seeking medical care on your behalf in case of a medical emergency while you are volunteering at Surrey. This information will be held in strictest confidence.Emergency contact name*Relationship*Cell phone number*Confidentiality Agreement and Release ClausesAs a Volunteer of Surrey Services, I agree that all individuals associated with Surrey have the right to privacy and confidentiality. To that end, I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning members, volunteers, staff, donors, agents and designees of Surrey Services, and not seek to obtain confidential information from any of the aforementioned individuals. Further, I understand that failure to maintain this Confidentiality Policy will result in termination of my volunteer relationship with Surrey. By my signature affixed below, I indicate that I have read, understand and agree to comply with the above statements. Type your name to sign*Date* MM slash DD slash YYYY Indemnification ClauseI hereby exonerate and hold harmless Surrey Services, its officers, directors, employees, volunteers, agents and designees from any and all injuries (including death) that may occur as a result of, or during my participation in volunteer activities for Surrey Services.Type your name to sign*Date* MM slash DD slash YYYY Photo Release ClauseI grant Surrey Services permission to publish photographs of me taken during my participation in volunteer activities. I understand that these images may be published in any manner, including advertising, periodicals, greeting cards, calendars and on the Surrey website. Said photos will be used expressly for the objective of educating the public about Surrey and volunteerism.Type your name to sign*Date* MM slash DD slash YYYY Volunteer Driver Escort (For those driving for Surrey ONLY.)I understand that as a driver for Surrey or any other Surrey Center service, my personal auto insurance is primary in the event of a claim and that any applicable deductible is my responsibility. Surrey Services carries additional liability limits which are secondary to my personal auto insurance policy. This coverage serves as excess should a claim exhaust the limits of my personal insurance. I agree to provide proof of a valid driver’s license and current automobile insurance to Surrey Services. Further, I understand that if I allow my automobile insurance to lapse, I may not be entitled to secondary automobile insurance coverage by Surrey’s insurance carrier.Type your name to signDate MM slash DD slash YYYY Volunteer AgreementAs a volunteer of Surrey Services for Seniors, you are an important member of our staff and act as a representative and ambassador of our organization to the community at large. For a better understanding of what you can expect from Surrey as a volunteer and what is expected of you, we ask that you read and sign this Volunteer Agreement. As Surrey Services commitment to you, we agree To provide you with beneficial and life-enriching experiences. To provide you with a safe environment in which to volunteer. To provide you with comprehensive orientation and general training sessions, plus any specialized training for specific jobs. To provide you with full access to your direct supervisor and the Volunteer Manager. To provide assurance that any recommendations, comments and concerns by you will be given full attention and will receive timely feedback. To provide you with opportunities for professional development and social interaction with other volunteers, members and staff. To provide a specific job description detailing duties and responsibilities, a Volunteer Handbook and any other necessary materials and supplies so that you may successfully fulfill the duties of your position. As my commitment to Surrey Services, I agree To conduct myself in an ethical and respectful manner at all times. To abide by the policies, rules and regulations of Surrey Services for Seniors as set out in the Volunteer Handbook and other organizational documents. To attend scheduled orientation and training sessions. To work the agreed-upon schedule for the position I fill. To record my hours on a time sheet by the 5th of every month for the prior month’s work. To notify my direct supervisor and/or the Volunteer Manager if you will be absent. By my signature affixed hereto, I declare that I have read, understand and agree with all parts of this Volunteer Agreement and will strive to fulfill all parts therein. Further, no promises of any kind have been made to me by any representative of Surrey Services for Seniors in exchange for my agreement hereto.Type your name to sign*Date* MM slash DD slash YYYY
