Author: Hogg, Linda

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

VOLUNTEER REGISTRATION FORM

Date:____________________ GENDER* M F *Required Information
NAME: * BIRTHDATE :*________________
ADDRESS:* RETIRED? Y / N
CITY* ST*_________ ZIP*_______________________
PRIMARY TEL#*:_______________________ CELL / LANDLINE ALTERNATE TEL#:_______________________ CELL / LANDLINE
EMAIL: TWITTER:_______________________
*BEST WAY TO CONTACT: EMAIL TEXT PHONE MAIL FACEBOOK HOURS A MONTH AVAILABLE TO VOLUNTEER_____
DO YOU DRIVE? YES NO ARE YOU INSURED: YES NO

Current or prior place of employment_____________________________________ Job Title_______________________________
Job Duties __________________________________________________________________________________________________________________________________________________________________________________________________
Do you like what you do? Why or why not? _________________________________________________________________________________________________
Specialized Skills (Examples: fundraising, marketing, computer use, web design) __________________________________________________________________________________________________________________________________________________________________________________________________
Tools/Equipment Used (Examples: large machinery, special computer software, construction site tools) _________________________________________________________________________________________________
If you could have the job of your dreams, what would it be? _________________________________________________________________________________________________
I currently volunteer for _________________________________________________________________________________________________
Name three organizations you would support if money and time weren’t an issue. 1._________________________________________ 2._________________________________________ 3._________________________________________

Areas of Interest / Traditional Volunteer Opportunities

___Baking	___Building a House	___Clean-up	___Clerical (secretarial)
___Delivering Meals	___Fixing Things	___Mentor/Tutor	___Providing Rides
___Serving Meals	___Other (please specify) _____________________

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

Beneficiary for Complimentary Volunteer Insurance (Use next of kin, spouse, child, etc.) There is a supplemental accident policy that will cover all volunteers during your volunteer work if you are registered in our volunteer database. You will also receive a supplemental liability and excess auto liability insurance that covers you while you are doing your volunteer work.
Name: Telephone: Relationship____________
Address: City /State / Zip_____________________________________
I, , volunteer my services through the Volunteers In Action 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, the undersigned, release Volunteers In Action and Barton County 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. The undersigned further agrees to indemnity and hold harmless the Volunteers In Action and Barton Community College, their trustees, directors, agents and employees, from any such liability, claims and demands.
X Date________________________
*Signature of Volunteers In Action Volunteer
X Date_______________________________ *Signature of Volunteers In Action Director

Thank you… for your volunteerism! You are enhancing the lives of those in your community with every small act of kindness.
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