RSVP Registration form

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 _____________________________________________________