Please complete this application form if you are interested in becoming a North Coast Opportunities Volunteer Network volunteer. Once you complete the form, click the Continue button at the bottom.

First and Last Name

First name/nombre:

Last name/apellido:

Birthdate: (MM/DD/YYYY)

Date of birth/Fecha de nacimiento::

Phone Number

Teléfono de casa/ Home phone:

Teléfono de trabajo/ Work phone:

Teléfono celular/Cell phone:

Mailing Address

Address, Apt, City, ZIP

Street/Calle:

Apt:

City/Ciudad:

State/Estado:

* Zip: *

Email

Email/Correo electrónico:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

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.

Age range/Grupo de edad:

Gender Pronouns/Pronombres de género:

Ethnicity/Origen Étnico:

T-Shirt Size

Please indicate your T-Shirt Size

T-Shirt size:

Comments:

Volunteer Skills, Interests and More

What Skills or interests do you have that you would like to share? Are you already assigned to an Americorps Senior program? If so, where are you assigned?
Which Volunteer Program are you interested in? (EKS VITA, CERT, RSVP, Foster Grandparent Program, etc.)
Are you a Veteran, Military member or Family of a Military member?

Emergency Contact Information

Please list an emergency contact (Name, Relationship, Mailing Address, Phone Number and Email)

First name/nombre:

Last name/apellido:

Street/Calle:

Apt:

City/Ciudad:

State/Estado:

Zip:

Teléfono de casa/ Home phone:

Teléfono celular/Cell phone:

Email/Correo electrónico:

Relationship/Relación:

BENEFICIARY FOR SUPPLEMENTAL ACCIDENT INSURANCE

Please enter your Beneficiary's full name and contact information in the box below.

Full Name, Relationship, Address (Street, City, State Zipcode,) Phone number (If applicable,) Email (If applicable)

NCO Volunteer Network: Volunteer Agreement

By checking the box below, I understand that I am not an employee of AmeriCorps Senior or The Volunteer Network, the sponsor, the volunteer station or the Federal Government and agree to serve without compensation. I further agree that if II use my personal automobile (if applicable) to and from my volunteer work station, I will arrange to keep in effect automobile liability insurance equal to or greater than the minimum required by the state.

STAFF AND VOLUNTEER CONFIDENTIALITY AGREEMENT

All Mendocino County employees and volunteers are required to protect every patron's right to privacy. This includes keeping confidential records and information maintained for the purpose of identifying the community members as well as information of their needs.

Staff and volunteers are also expected to keep other information confidential such as keyed access codes, database logins, and personal contact information of staff, volunteers and the identity of anonymous donors. Staff and volunteers working under Mendocino County Volunteer sites/request must sign and adhere to this policy of confidentiality.

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As a Mendocino County or NCO Volunteer Network staff person or volunteer, I understand and agree to the "Staff and Volunteer Confidentiality Agreement" as described above. I also understand that violating this policy may result in disciplinary measures, up to and including termination from my employment or if I am a volunteer, may result in my dismissal from my volunteer position.

I Agree