Author: Hogg, Linda

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

YOUTH VOLUNTEER REGISTRATION FORM

Date:____________________ *Required Information
NAME: * GENDER* M F
BIRTHDATE :*________________
ADDRESS:*
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 (Only required for Volunteer Drivers) DRIVERS LICENSE NUMBER_________________________________ EXP________________

gRADE_____________________________________SCHOOL_______________________________
FAVORITE SUBJECTS AND CLASSES __________________________________________________________________________________________________________________________________________________________________________________________________
HOBBIES—WHAT DO YOU LIKE TO DO WHEN YOU’RE NOT AT SCHOOL? __________________________________________________________________________________________________________________________________________________________________________________________________
I currently volunteer for _________________________________________________________________________________________________
If you could have the job of your dreams, what would it be? _________________________________________________________________________________________________
Name three WAYS YOU’D LIKE TO CHANGE THE WORLD AROUND YOU 1._________________________________________ 2._________________________________________ 3._________________________________________
ANYTHING ELSE YOU’D LIKE TO SHARE WITH OUR OFFICE ABOUT YOURSELF?

Areas of Interest / Traditional Volunteer Opportunities

___Baking	___Clean-up	___Delivering Meals	___Helping a neighbor
___Providing rides	___Reading to children	___Reading to the elderly	___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 Parent/Guardian
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.
For up to date information on what we are doing, like us on Facebook! https://www.facebook.com/volunteersinactionpage
Or scan this QR code using your smartphone.