Coles County Retired and Senior Volunteer Program
Sponsored by Coles County Council on Aging
11021 E. Co. Rd. 800N
Charleston, IL  61920
217.639-5165                         217.639-5199(fax)
marilyns@colescouncilonaging.org         tracyp@colescouncilonaging.org

VOLUNTEER REGISTRATION FORM
NAME  DATE 
CITY, STATE, ZIP  BIRTH DATE 
 EMAIL 

Please check ALL that apply to you.  This data is for statistical analysis.  Submission of information is voluntary.
Ethnic:     Hispanic or Latino          Non Hispanic
Race: American Indian  Asian  Black/African Amercian  Native Hawaiian or Pacific Island  White

Retired From  Position 
How did you hear about RSVP? 
Method of transportation     own car     * Dial-a-Ride     with a friend     other 

*I understand that if I use my personal automobile in my volunteer service, I will arrange to keep in effect automobile liability insurance equal to the minimum limits required by the state of Illinois.
                                                                                                    Driver’s License Number 
In case of emergency, please contact:      NAME      PHONE 

When submitting this form, I understand that I am not an employee of the Coles County Council on Aging (CCCoA) or the Coles County RSVP.

RSVP is required to carry supplemental accident, personal liability, and excess automobile insurance coverage on its volunteers.  Contact office for more information.
I do not have a beneficiary; please designate benefits to my estate.
Beneficiary for RSVP Accident Insurance
     NAME         RELATIONSHIP        
ADDRESS   
CITY, STATE, ZIP        PHONE   


Coles County Council on Aging
11021 E. Co. Rd. 800N
Charleston, IL  61920-8632
Phone:  217.639.5150
Fax:  217.639.5199
lifespancenter@colescouncilonaging.org