RSVP Enrollment Form

Retired & Senior Volunteer Program (RSVP) Enrollment Form
Please complete all sections. Forms with original signatures are required for enrollment.
Name*
Birth Date*

MonthDayYear
Mailing Address*
City*
Zip*
Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Are you a veteran?*

YesNo
Physical/Medical Limitations*
Have you ever been convicted of a criminal offense or misdemeanor?*

YesNo
If yes, please attach an explanation of charges, date of offense, and status of the charges on a separate sheet to be included with this application.*

Cancelof
Do you have a personal vehicle with Texas State Insurance?*

YesNo
As a City of Corpus Christi RSVP Program, you will be covered by accident, personal liability, and excess automobile insurance CIMA while performing volunteer duties. This coverage is automatic and free of cost to you if you are an active, enrolled as a City of Corpus Christi RSVP volunteer. Please provide the following information.
Emergency Contact*
Phone*
Beneficiary for AmeriCorps Seniors RSVP Supplemental Accident Insurance:
Name*
Relationship*
Address*
Phone*
Employment Experience*
Special Skills/Interests/Languages*
Volunteer Experience (Current, Past, Preferred)*
Days/Hours Available: *

MonTuesWedThuFriMorningsAfternoons
Select your shirt size:*

SmallMediumLargeXLargeXXLargeXXXLarge
Please indicate if the City of Corpus Christi RSVP Program may have permission to use your likeness?*

I hereby grant the City of Corpus Christi RSVP Program permission to use my likeness in photograph(s)/video(s) in any and all of its publications or on the world wide web, whether now known or hereafter existing, controlled by the City of Corpus Christi RSVP Program in perpetuity. I will make no monetary or other claim against the City of Corpus Christi RSVP Program for the use of these photograph(s)/video(s).I do not give permission to use my likeness in photograph(s)/video(s) to the City of Corpus Christi RSVP.
By signing below, I acknowledge that I have read and understand the following statements:

As specified in 42 U.S.C. § 5043(c) and 45 CFR § 2553.91, while charging time to an RSVP grant, accumulating service or training hours, or otherwise performing activities supported by the RSVP grant or AmeriCorps, staff and volunteers may not engage in the following activities:
- Religious and Political Activities: Volunteers will not engage in religious or political activities or instruction.
- Displacement of Employees: Volunteers will not be assigned to any job duty that would displace employed workers.
- Compensation for service: Under no circumstances shall a RSVP volunteer receive a fee for service from service recipients, their legal guardian, members of their family, or friends.
- Prohibition of Discrimination: As a RSVP volunteers The City of Corpus Christi RSVP Program will not discriminate against RSVP Volunteers basis on age, race, creed, color, national origin, gender, sexual orientation, gender identity or expression, genetic predisposition, carrier status, marital status, Vietnam Era Veteran status, or based on disability, if the volunteer is a qualified individual with a disability.
- Accessibility and Reasonable Accommodation: Reasonable Accommodations will be provided to volunteers to known disabilities of individuals in compliance with the Americans with Disabilities Act.
- Abortion Services or Referrals: RSVP volunteers may not engage in providing abortion services or referrals for receipt of service.
- I understand that in my capacity as a City of Corpus Christi RSVP Program Volunteer, I may encounter confidential information. I agree to protect this information to the best of my ability and not to disclose it during or after my service as a volunteer has ended.
- Background Checks: The City of Corpus Christi Park and Recreation RSVP does not conduct criminal background checks on RSVP volunteers, but some volunteer stations will conduct their own background checks.
RSVP Volunteer Signature*

Clear
Date*

MonthDayYear
Certifications

By signing below, I acknowledge that I have read and understand the following statements:
- I hereby state that I am 55 years of age or older and offer my services as a volunteer for the City of Corpus Christi RSVP Program. I understand that I am not an employee of the City of Corpus Christi RSVP Program, the sponsor, City of Corpus Christi, the volunteer station, or the Federal Government and agree to serve without compensation.
- Separation from Volunteer Service: The volunteer station may request the removal of an age 55 and over adult volunteer(s) by contacting RSVP staff. Parties will work together to resolve conflicts.
RSVP Volunteer Signature*

Clear
Date*

MonthDayYear
Staff Signature

Clear
Date

MonthDayYear
AmeriCorps Seniors RSVP is often asked to provide demographical information pertaining to volunteers. Please provide the following information. (Optional)
Are you an active military member?*

YesNo
Are any of your family members actively serving in the military?*

YesNo
(Optional) Gender:

MaleFemale
(Optional) Race/Ethnic Background:

WhiteAsianAfrican AmericanHispanic/LatinoAmerican Indian/Alaska NativePacific IslanderOther
Equal Employment Agency - The City of Corpus Christi RSVP Program is an equal opportunity Agency. Enrollment is done without regard to race, color, religion, national origin, sex, age, or disability.

City of Corpus Christi RSVP Program provides reasonable accommodations to the known disabilities of individuals in compliance with the Americans with Disabilities Act.

For accommodation information or if you need special accommodations to complete the application process, please contact The City of Corpus Christi RSVP Program at (361) 826-3136.
Thank you for your interest.

You will receive a reply within three business days. If you have any questions, please send an email to Ericka@cctexas.com or AngelM@cctexas.com, or call

(361) 826-3136.
Corpus Christi Parks & Recreation - RSVP

4040 Greenwood Drive, Corpus Christi, Texas 78416 | (361) 826-3136.
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Retired & Senior Volunteer Program (RSVP) Enrollment Form