Enrollment Form

IDA RSVP is an Equal Opportunity Agency: Enrollment is done without regard to race, color, religion, national origin, sex, age or disability. AmeriCorps Seniors RSVP 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 idarsvp@iowa.gov. Thank you for any information you have provided. Your information is never sold, shared, or used outside of AmeriCorps Seniors RSVP, AmeriCorps Seniors or IDA RSVP.

Applicant Information

First Name *

Last Name *

Address *

City *

State

Zip Code * Ex. 55555-5555

County of Residence *

Preferred Phone Ex. 555-555-5555

Secondary Phone Ex. 555-555-5555. Required if no home phone provided.

Gender *

Date of Birth * MM/DD/YYYY

Marital Status *

Who do you live with? (Check all that apply) *

Alone

Spouse

Family

Other

If other, please provide

About You

Every effort will be made to match you with a Friendly Neighbor volunteer who shares your interests and can accommodate your schedule. Preferred time of calls (check all that apply): *

9am - Noon

Noon – 4pm

4pm – 6pm

Personal Interests (pets, hobbies, prior career, etc.)

Have you served in the US Military? *

Yes

Statement of Understanding

I understand that this Emergency Contact information will be given to the Call Program staff and that the staff will contact the individuals listed above if needed. These individuals have been notified by me and agree to their inclusion on this list.

I understand that I have requested that a Call Program volunteer call me at a pre-arranged time. I further understand the Neighbor to Neighbor Call Program is a telephone reassurance program and is not a referral service, telemedicine provider or medical alert service.

If I am not going to be home to receive a call, I will inform the Call Program staff office no later than the day before. If I am unable to reach the Call Program staff, I will leave a voice message notifying staff of the change.

I understand that there will be no charge for this service and that its success will depend on my cooperation.

I permit IDA RSVP to share my name and telephone number for the purposes of administering the Call Program.

I have read and understand the details of the Neighbor to Neighbor Call Program and agree to the conditions of my participation.

I agree and understand the above Statement of Understanding *

The Neighbor to Neighbor Call Program volunteer will call you at a pre-arranged time. In the event that the volunteer is unable to reach you after at least two attempts 15 minutes apart and allowing the phone to ring 15 times, we highly recommend that you designate one or more emergency contacts to allow the Call Program staff to contact the person(s) you designate.

Designate Emergency Contact(s) (optional)