First name: * Last name: * Street address: * City: * State: * North Carolina Zip code: * Email address (if any): * Phone number (home or cell): * Phone number (work): Employer (if retired, former employer): * Date of birth (optional, month/date): Are you (the volunteer) under 18 years of age? * Yes No Please check all that apply. This child is permitted to: If the volunteer is under 18 years of age, the signature of a parent/guardian is required * Assist in meal delivery by driving their own car Assist in meal delivery by riding in the car of another volunteer Other (packing, loading meals, administrative work within the Meals on Wheels of Durham building) Parent/Guardian Signature * I, as the parent/legal guardian of the under-18 volunteer, permit this child to perform the selected volunteer functions, above. How did you hear about us? * Let us know how you learned about volunteering with us! DRIVER'S LICENSE AND VEHICLE INFORMATION Driver’s license number * State issued: * Expiration date: * Vehicle insurance company: * Policy number * Expiration date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20202021202220232024202520262027202820292030 EMERGENCY CONTACT INFORMATION First name: * Last name: * Relationship to you: * Phone number: * OTHER INFORMATION Do you belong to a club, group, or civic organization? * Yes No If yes, please provide name: Do you belong to a local house of worship? * Yes No If yes, please provide name: Is your volunteer interest in order to fulfill community service hours? * Yes No What type of community service hours are you looking to perform? * For a school requirement Recommended by my attorney Court-ordered Other Please provide contact name and phone number for your community service: We need the contact name and phone number of the person (school administrator, attorney, court, or other) who is supervising your community service hours. Thank you! Have you ever been convicted of a felony or misdemeanor classified as an offense against a person or family? * Yes No If yes, please explain: AGREEMENTS STATEMENT OF LIABILITY: Meals on Wheels Durham 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 his or her own insurance covering these and other risks. STATEMENT OF LIABILITY * CONFIDENTIALITY STATEMENT: It is understood that as a volunteer of Meals on Wheels Durham, 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 Meals on Wheels Durham divulge recipient information to anyone outside the organization. CONFIDENTIALITY STATEMENT * BACKGROUND CHECK ACCEPTANCE: Meals on Wheels Durham reserves the right to conduct criminal background checks on volunteers who will be interacting with meal recipients. The volunteer will always be given notice and a statement of their rights regarding such background checks in advance of conducting any such check. Meals on Wheels Durham reserves the right, pending the results of such checks, to decline to allow a volunteer to deliver meals to their clients. BACKGROUND CHECK ACCEPTANCE * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
