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Agency Train-the-Trainer Volunteer Enrollment Form

Are you participating in the Train the Trainer Program through your employer or behalf of another organization? If yes, enter organization's name.(Required)

Yes

Organization Name(Required)

What best describes your relationship to the agency?(Required)

Salutation

First name(Required)

Last name(Required)

Legal Name(Required)

Other Names (including maiden, aliases, and nicknames)

Street Address(Required)

City(Required)

State(Required)

Zip(Required)

County of Residence(Required)

Phone Number(Required)

Cell Phone Number

Birth Date(Required)

Email Address(Required)

Ethnicity (Optional)

If you selected Multiple Ethnicity/ Other, please specify.

Please share any issues that could affect your volunteer placement (medical, physical, behavioral health). Accommodations will be made, when possible. This information will not be shared without your consent.

Please indicate your primary language(Required)

Are you fluent in a secondary language? If so, please specify.

What devices are you comfortable using?(Required)

Are you a veteran?(Required)

Yes

Is anyone in your household a Veteran?(Required)

Yes

Person to notify in case of emergency

First Name(Required)

Last Name(Required)

Phone Number(Required)

Do you consent to RSVP conducting criminal background checks?(Required)

Yes

Do you have a criminal history of a felony within the last five years?(Required)

Yes

Have you been a resident of the State of Pennsylvania continuously for a minimum of ten years?(Required)

Yes

Have you been a resident of the State of Pennsylvania continuously for a minimum of two years?(Required)

Yes

As an RSVP volunteer, I understand and accept responsibilities associated with my position. General responsibilities are outlined in the RSVP Volunteer Handbook. There may be additional program-related requirements.

I grant permission to RSVP inc. to use photos taken of me for use in RSVP publications, newspaper articles and other forms of marketing and identification materials.

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Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide RSVP regarding and agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or third party verification is necessary to validate your E-Signature.

______________________________________________________

Agreement(Required)

I Accept

I Decline

Your initials below represent your signature(Required)

Today's Date(Required)

In order to process this enrollment form, we need a copy of a valid, State issued photo ID to verify your identification. Please upload your ID. If you need assistance, call 610.834.1040 x123(Required)

Did you attach your Identification?(Required)

Yes