AmeriCorps Seniors RSVP Volunteer Enrollment Form

RSVP TRANSPORTATION REIMBURSEMENT BENEFIT

You may be eligible for partial reimbursement of $2 per day you volunteer to assist with travel costs you incur as a volunteer. The maximum reimbursement is 10 days per month. Your reimbursement amount is based on monthly timesheets submitted to RSVP by the site where you volunteer. You are not eligible if you walk to your assignment or if you are a member of the organization where you volunteer, like a Senior Center.

Do you want to receive partial transportation reimbursement from RSVP?

What is the primary way you will travel to your volunteer assignment?

*If you selected drive, please keep in effect a valid Driver's License and automobile liability insurance equal or greater than the minimum requirments of your state.

RSVP SUPPLEMENTAL INSURANCE BENEFIT

While your health and safety is our top priority, accidents sometimes happen. That is where our supplemental insurance policy and request for emergency contact information comes in.

While performing volunteer duties as an AmeriCorps Seniors RSVP volunteer, you are covered by supplemental accident and personal liability insurance, including a $2500 accidental death benefit (in effect only when acting as an RSVP volunteer.) This coverage is automatic and free of cost while you are an active, enrolled member of RSVP.

Please provide the name of an emergency contact who would be contacted in the unlikely event of an emergency. Please provide the name of a beneficiary who should receive the accidental death benefit in the unlikely loss of life while volunteering. The beneficiary can be a relative or friend. You cannot name yourself as a beneficiary.

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact Email

Is your Beneficiary the same as your Emergency Contact?

Beneficiary Name

Beneficiary Relationship

Beneficiary Email:

Beneficiary Phone Number

PLEASE NOTE

*AmeriCorps Seniors volunteers cannot perform the following PROHIBITED ACTIVITIES as part of their volunteer service, even if only temporary: give religious instruction, conduct worship services, or engage in proselytizing; assist with electoral activities, voter registration, transportation to the polls, or try to influence legislation; engage in activities that displace paid workers; accept money or donations from service recipients or their relatives and friends; and provide abortion services or referrals for receipt of such services.

CERTIFICATION AND ELECTRONIC SIGNATURE

I hereby certify that I am 55 years of age or older and offer my services as a volunteer to the AmeriCorps Seniors RSVP program. I understand that AmeriCorps Seniors RSVP volunteers are not considered employees of the local RSVP project, CSS, the organization where they serve, or the federal government, and agree to serve without compensation. I further state that I am aware of the Prohibited Activities and will not engage in these activities while serving as an AmeriCorps Seniors volunteer.

Typing your name here will serve as your electronic signature on this AmeriCorps Seniors RSVP Volunteer Enrollment Form:

Date

AmeriCorps Seniors RSVP in New York City is a grantee of AmeriCorps, the federal agency connecting individuals to service to tackle the nation’s most pressing challenges. We are sponsored locally by the Community Service Society of New York (CSS).