MEALS ON WHEELS OF CHEMUNG COUNTY INC.

VOLUNTEER REGISTRATION

We cannot thank you enough for giving your time to us!!!!

Name Date____________________________

(Please Print)

Address Home Phone____________________

City/State/Zip Work Phone_____________________

Birth date: Month Day Year (Optional)

Emergency Contact NAME & NUMBER Relationship______________

DAY(s) PREFERED: (Check all that apply)

Once per week ON: Monday Thursday

More than once a week Tuesday Friday

As a substitute Wednesday No Preference

POSITION(s) AVAILABLE: (Please check preference)

Server Driver Driver & Server Kitchen Aide

* I have a car available ___ Yes ___ No

* Do you have a valid driver’s license? ___ Yes ___ No

Enter Driver’s License # State

I have auto insurance with

* Do you have any health limitations? ___ Yes ___ No

Please list

* Do you have a criminal record? ___ Yes ___ No

If applying for a driver’s position, is there a specific area you would prefer? i.e. Southside, Horseheads

Please specify if applicable

HOW DID YOU HEAR ABOUT US: (check all that apply)

News paper Volunteer/Friend Radio Speaker______

Church (name) Other (please list)

I hereby grant Meals on Wheels permission to use my photograph in conjunction with my name

or a fictitious one for reproduction in advertising, display or editorials.

Meals on Wheels recipients come from diverse background. As a volunteer you agree to serve any

recipient assigned on a route regardless of race, creed, origin, or health. I have read and understand

my job responsibilities and agree by signing below:

Date Volunteer Signature

Coordinator Signature

Please list your volunteer experiences here: (Organization, position and year(s) worked):

01/31/04

MEALS ON WHEELS OF CHEMUNG COUNTY, INC.

VOLUNTEER DISCOLAIMER

I, ________________________ acknowledge that I have read my job responsibilities and fully understand that I will be acting solely as a volunteer for Meals on Wheels. As a Meals on Wheels volunteer I will not receive any monetary compensation, nor will I represent myself as an employee of Meals on Wheels.

I understand and agree that should I be injured, become ill, or otherwise require any form of medical treatment in the course of acting as a Meals on Wheels volunteer, that I waive any claim against Meals on Wheels attributable to such circumstances.

I also understand that Meals on Wheels provides meals for homebound disabled persons and that during the course of my volunteer duties, I may learn certain information about the recipient and including but not limited to his/her disability. I understand that this information is strictly confidential and I will not disclose it to any person or entity.

_________________ ______________________________

Date Volunteer Signature

____________________ ____________________________________

Date Meals on Wheels Representative