How did you find out about us?

Areas of Interest

Information about our opportunities

Are you applying for a volunteer position in order to fulfill a class requirement? Yes No
If so, how many hours do you need to complete? and by what date?

We cannot fulfill court-ordered community service hours.

Time Availability

I am Flexible or:
Preference of Days
Hours available (Morning, Afternoon, Evening)

Do you have a vehicle? Yes No
If no, explain how you will have reliable transportation:
(you will not be expected to transport client, but will need to be at necessary appointments.)

Have you ever been convicted of a crime? required

Due to the nature of the clients we serve, Agency policy restricts the use of a volunteer with any type of criminal background history.

References

Release of Information
Please read explanations below and check all boxes

Releases:

CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT:
I have been informed of REAL Services’s policy on the confidential nature of certain client information. I agree to sign a Confidentiality and Non-Disclosure Agreement.

CRIMINAL BACKGROUND CHECK:
*We require criminal background checks for all volunteers except those participating in seasonal group projects and Safe at Home. I understand that REAL Services requires criminal history and/or driving record background checks for the purpose of evaluating me for a volunteer position. I understand that a background check is a consumer report which is covered under the Fair Credit Reporting Act, and I have received a copy of my rights under the FCRA. The consumer report may include the following areas: verification of social security number, criminal history records, and motor vehicle records to include traffic citations and registration. I hereby authorize REAL Services to obtain a Consumer Report, to verify information that I have voluntarily supplied. This authorization and consent shall be valid in original, on-line, fax or copy form. I certify that the information contained on this form is true, correct and complete to the best of my knowledge. I also understand that any misrepresentation, falsification or omission of facts herein may be grounds for disqualification or separation.

If a volunteer decision which adversely affects me is made based upon information obtained through a consumer report, I understand that I have the right to request a free copy of the report. If I dispute the information, I have the right to conclusively demonstrate the inaccuracy of the information

LIABILITY RELEASE:
In consideration of the opportunity afforded me to participate in this project, I hereby agree that I, my assignees, heirs, guardians, and legal representatives will not make a claim against REAL Services Aging & In-Home Solutions, or any of its affiliated organizations, or either of their officers or directors collectively or individually, or the supplier of any materials or equipment that is used in the project, or any of the other volunteer workers, for the injury or death to me arising from my participation in the project. Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of actions resulting from personal injury or death to me sustained in connection with my participation in the project.

PHOTO RELEASE:
I certify that I am twenty-one years of age or over and hereby voluntarily and without compensation give REAL Services Aging & In-Home Solutions (the organization), its successors and assigns and those acting under its permission or upon its authority, the unqualified right and permission to reproduce, publish, circulate or otherwise use my name and/or likeness of me in which I may be included in whole or in part. I waive any right to inspect and approve the finished product or copy that may be used or the use to which it may be applied. This authorization and release covers the use of said materials in any published or broadcast form and any medium of advertising or publicity.

VOLUNTARY PARTICIPATION AND EXECUTION:
I acknowledge that I have willingly agreed to serve as a volunteer for the REAL Services Aging & In-Home Solutions Volunteer Program. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and REAL Services Aging & In-Home Solutions, and I sign it of my own free will.

I Agree

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Your ID will be checked and/or copied upon volunteer orientation for all REAL programs. If you are applying for a volunteer position to deliver Meals on Wheels or for Guardianship, you will need to provide a copy of your driver's license and proof of insurance at the time of the interview.

I acknowledge and agree that all information provided herein is accurate and true and hereby authorize REAL Services, Inc. to verify such information, contact references and conduct a criminal background check. I understand that I will not be paid for my services, as this is strictly volunteer work. I have read and understand the above statements.

Agree Disagree

Date:

Electronic Signature: