Youth Volunteer Application
Hillsdale County United Way & Volunteers In Action
P.O. Box 203, 30. N. Howell St., Suite 21.
Hillsdale, MI 49242
Phone: 517-439-5050 1-800-VOLUNTEER
Fax: 517-439-5058
http://www.hillsdalecountyunitedway.org

Today's Date:_______________
Name:____________________________________ Phone:_________________________________
Address:____________________________________________________ Birth Date:________
City: :____________________________________ State:_____ Zip Code:________________
Email:____________________________________ School:________________________________
Graduation Year:___________________________ Current Grade:__________________________

Special Events / Areas of Interest: Please circle the ones you are interested in.
Adopt-A-Grandparent
Animal Shelter
Big Brother/Big Sister Mentor
Blood Drive
Booth Helpers
Camp Counselor
Child Care
Community Easter Egg Hunt
Computer Tutoring
Crafts
Data Entry, Computer
Food Pantry
Habitat For Humanity
Hanging Posters
Homeless Shelter
Kid's Fest
Mailings
Making Copies
Nursing Home Visitor
Pumping Gas
Relay For Life
Salvation Army Bell Ringing
Tutor
Web Page Design
Yard Work
Youth Board
Other - List___________________________________

Please list any special interests or skills you have:
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Have you ever volunteered before? ________Yes ________No
If yes, where and when? __________________________________
__________________________________________________________
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Desired volunteer time
________Fall ________Summer ________Mornings ________Evening
________Winter ________Spring ________After School ________Weekends

Emergency Contact Person:
Name: ________________________________________Phone: ______________________

Disclaimer:

• I volunteer my services through Hillsdale County United Way & Volunteers In Action and understand that I am not an employee of United Way or the groups I help.
• I consent to the use of my name and/or photograph in any of the media.
• I agree to regard all information received in the performances of my volunteer work as confidential. I further agree to respect individual rights to privacy, as well as those of the family and the facility for whom I am volunteering.
• If I use my personal vehicle in my volunteer service, I will keep current automobile liability insurance equal to the minimum limits required by the State of Michigan. I will not be reimbursed for gas/mileage.
• I hereby grant permission to Hillsdale County United Way & Volunteers In Action to check with the appropriate authorities (courts, police, and Department of Motor Vehicles) upon matters of record regarding my background and history. Any information obtained will be kept strictly confidential.
• I understand that all the information provided / obtained in this registration will be kept confidential.

Volunteer's Signature: ________________________________ Date: ______________

Parental/Guardian Consent
If you are under 18 years of age, or have a legal guardian, you MUST have the release signed by your parent/guardian before we can consider you for volunteer opportunities.

Release
I certify that the statements made in this volunteer application are true and correct, and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release Hillsdale County United Way & Volunteers In Action from any liability whatsoever for supplying such information. Hillsdale County United Way & Volunteers In Action is released from any liability in referring me to an agency and any liability that may arise when working for such agency.

Parent Permission Slip: (Must be signed by parent before you can volunteer)
______________________________________ has my permission to consider and/or accept volunteer opportunities referred to him/her by Hillsdale County United Way & Volunteers In Action.
Parent/Guardian signature: ______________________________________ Date:________________
Medical conditions of my child that you should be aware of: ____________________________________________________________
____________________________________________________________
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Youth Volunteer Application
Hillsdale County United Way & Volunteers In Action
P.O. Box 203, 30. N. Howell St., Suite 21.
Hillsdale, MI 49242
Phone: 517-439-5050 1-800-VOLUNTEER
Fax: 517-439-5058