Linn Benton

250 Broadalbin, Suite 2A
Albany, OR 97321
(541) 812-0849                    
Fax (541)967-9307

Benton Center  
545 SW 2nd. St., Suite A

Corvallis, OR  97333

(541) 753-9197                    
Fax (541) 757-9537

Today’s Date ____/____/________

Name: _______________________________________________ Date of Birth: _____/_____/____
Street Address: _______________________________ City: __________________ Zip: _________
Mailing address (if different from street): _____________________________________________
Telephone No: ____________________  Email Address: __________________________________
Disabled: Yes   No    Physical Limitations: _______________________________________
Past Employer/Occupation: __________________________________________________________
Volunteer service/experience: _______________________________________________________
Do you want us to contact you with more volunteer opportunities? Yes    No
Volunteer interest areas: (What would you like to do?) __________________________________
How did you hear about RSVP? _______________________________________________________
May we use your photograph in publications?  Yes    No
Emergency Contact: Name _____________________________ Telephone No. ________________

VOLUNTEER CAR INSURANCE STATEMENT
Do you have a car?  Yes   No   Driver’s License # ____________ State _______ Exp.______

I, the volunteer, understand that if I use my personal automobile in my volunteer service, I will 

keep the automobile insurance equal to the minimum limits required by Oregon.

NAME OF AUTO INSURANCE COMPANY, not Agent: ___________________________________

DESIGNATION OF BENEFICIARY (For RSVP Accident Insurance)
Name(s): _________________________________________ Relationship: ______________________
Address: ____________________________ City: ________________ State: _____ Zip: ___________

ETHNIC DATA*
White, not Hispanic  1 Black, not Hispanic  Hispanic  Asian/Pacific Islander   
American Indian/Alaskan Native  *Providing ethnic information is voluntary. It is used for 

statistical information only. Your records are entirely confidential.

X_____________________  ___________   X__________________________    ____________
Signature of Volunteer           Date                    Signature of RSVP Staff                  Date                                                         
RSVP Office Use:

Volunteer Registration Number _________ Job Placement _________________________________ Mailed____