Please complete this application form if you are interested in becoming a Walworth County volunteer. Once you complete the form, click the Continue button at the bottom.

Name and address


Emergency Contact


Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.


Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.


Assignment Preferences

Please indicate the days and times you are available to volunteer.


Availability


Skills


About You

Please tell us about your other skills and interests.


Agreement

ACKNOWLEDGEMENT OF CONFIDENTIALITY: As a volunteer/intern, I agree that matters pertaining to consumers of Walworth County are confidential. I understand that the use or disclosure of clients protected health information (PHI) will violate local, state, and federal confidentiality provisions and laws.
VEHICLE USE AGREEMENT: If operating a personal vehicle for County business, I currently possess a valid driver's license and maintain automobile liability insurance coverage.
USE OF PHOTO/IMAGE: I give Walworth County Volunteer Services consent to use my photo/image in ways to help promote volunteerism in such P.R. means as newsletters, social media, printed media, etc.
CONSENT: I hereby authorize Walworth County and/or its agents to make an independent investigation of my background, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information provided on this form. I release Walworth County and/or its agents and any persons or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above reference sources used. I attest that the above is my true and complete legal name and date of birth and all information is true and correct to the best of my knowledge.