Volunteer Application

First name

Last name

Birthday

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

FOR DRIVERS ONLY: Enter Driver's License # and Auto Insurance/Policy #

Fluvanna Meals on Wheels delivers Monday-Friday. Kitchen shifts are 9:20am to 10:30 am. Drivers arrive between 10:00 and 10:15-no later than 10:30. Most routes take about an hour to complete.

I would like to volunteer to be one or more of the following positions:

Regular Driver (same route, same day each week or every other week)

Substitute Driver for my regular route

Substitute Driver in an emergency

Substitute Driver on call/as needed

Meal Packer (Kitchen)

Substitute Meal Packer (Kitchen)

Office Volunteer

Client Services Committee (delivers birthday bags-day/evenings/weekends)

Snack and a Smile (delivers a snack and makes longer visit)

Reference:

Name

Phone

Address

Emergency Contact:

Name

Phone

Address

Have you been convicted of a motor vehicle violation in the past five years?

Yes

Have you been convicted of a criminal violation?

Yes

Are you currently under investigation for a felony offense?

Yes

If you answered yes to any of the above questions, please explain:

Statement of Liability

Fluvanna Meals on Wheels, INC. is not responsible for personal injuries or property damage suffered or caused by a volunteer in connection with his or her volunteer activities. As a condition to serving as a volunteer, each volunteer is expected to maintain their own insurance covering these and other risks.

Confidentiality Statement

It is understood that as a volunteer of Fluvanna Meals on Wheels, INC. you will protect the privacy of all those we serve by maintaining strict confidentiality when discussing meal recipients and the nature of their health conditions. Under no circumstances should a volunteer from Fluvanna Meals on Wheels, INC. divulge recipient information to anyone outside the organization. I will not accept any compensation or other form of remuneration from any Fluvanna Meals of Wheels, INC. meal recipients and I will not solicit Fluvanna Meals on Wheels, INC. meal recipients for any purpose.

Consent and Release

I hereby authorize Fluvanna Meals on Wheels, INC. and its affiliates or those acting with its permission to use, reproduce, and distribute my name, voice, likeness, photograph, and/or any other representation of me in connection with printed materials or other media it distributes, displays, transmits, or exhibits.

I hereby certify that the information provided on this application form is true and verifiable.

Signature

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Thank you for volunteering with Fluvanna Meals on Wheels!