Lyon County RSVP Volunteer Enrollment Form Sponsored by Lyon County Department on Aging 402 Commercial Street, Room 106 (physical address) 430 Commercial Street (mailing address) Emporia, Kansas 66801 620-342-6119 |
Please print and complete all sections.
Name __________________________________ Birth Date _____________________
Street Address ___________________________ City, Zip ______________________
Mailing Address __________________________ City, Zip ______________________
Phone _____________________ Cell Phone _________________ Sex M F
Do you have a car? Yes No Veteran Yes No
Persons to notify in case of emergency
Name: ____________________________ Name: _____________________________
Telephone: ________________________ Telephone: __________________________
Relationship: ______________________ Relationship: ________________________
Physical Limitations: ______________________________________________________
_________________________________________________________________________
Employment Experience ___________________________________________________
Skills/Interests/Languages _________________________________________________
Volunteer Experience: _____________________________________________________
Preferred Volunteer Assignments:
1. _____________________________ 2. __________________________________
Days/Hours Available _____________________________________________________
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