Volunteer Application (Fields marked with an asterisk* are required)

Last Name*

First Name*

M.I.

Date* (E.g., 01/20/2020)

Street Address*

Apartment/Unit #

City*

State*

ZIP Code*

Telephone* (E.g., 909-621-4018)

Email*

Cell Phone

Languages Spoken Fluently*

Have you ever been convicted of a felony?* Have you ever been convicted of a felony?* YES NO

If Yes explain:

Are you interested in becoming a Driver for Meals on Wheels? (If you choose not to become a Driver, skip ahead to the line that says, "I will not be a driver for Meals on Wheels")* Are you interested in becoming a Driver for Meals on Wheels? (If you choose not to become a Driver, skip ahead to the line that says, "I will not be a driver for Meals on Wheels")* YES NO

Auto Insurance Company

Driver's License Number

Have you ever had your license suspended, revoked or refused? Have you ever had your license suspended, revoked or refused? YES NO

In the past 10 years have you been convicted of driving while intoxicated or under the influence of drugs? In the past 10 years have you been convicted of driving while intoxicated or under the influence of drugs? YES NO

If yes, please explain:

I hereby agree that as a driver for Claremont Meals on Wheels I will maintain both bodily injury and property damage liability coverage in the amount of at least $50,000 per accident. In the even that such coverage lapses, I agree to notify MOW immediately. (SIGN YOUR NAME IN THIS BOX.)

OR, I WILL NOT be a driver for MOW. (SIGN YOUR NAME IN THIS BOX.)

Date* (E.g., 01/20/2020)

Are you a veteran?* Are you a veteran?* YES NO

Date* (E.g., 01/20/2020)

Work and Volunteer Experience* (E.g., Animal shelter volunteer)

Volunteer Positions: Please check off your interest(s)*: Volunteer Positions: Please check off your interest(s)*: Day Captain Intake Packer Driver Navigator Routing Substitute College Student Hours

In case of emergency, please contact (ENTER FULL NAME IN THIS BOX)*:

Phone* (E.g., 909-621-4018)

Relationship* (E.g., Husband, wife, parent)

I have received and understand the training given to me in the Claremont Meals on Wheels "Safety Guide". I will report any hazards I observe and will practice safety myself. (SIGN YOUR NAME IN THIS BOX.)*

Date* (E.g., 01/20/2020)

I agree to release Claremont Meals on Wheels ("MOW") from all liability relating to injuries that may occur during my volunteer activities. I acknowledge the risks involved in volunteer activities, in which I am participating voluntarily. I also fully understand that MOW does not assume responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury illness, death or property damage. I will also make every effort to obey safety precautions as listed in writing and explained to me verbally. I hereby release and forever discharge and hold harmless MOW and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either law or in equity, which arise or may hereafter arise from my volunteer activities with MOW. *PHOTO RELEASE: I hereby grant and assign MOW all rights, title and interest in all photographic images and video or audio recordings that are made during my work with MOW.* I agree to release Claremont Meals on Wheels ("MOW") from all liability relating to injuries that may occur during my volunteer activities. I acknowledge the risks involved in volunteer activities, in which I am participating voluntarily. I also fully understand that MOW does not assume responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury illness, death or property damage. I will also make every effort to obey safety precautions as listed in writing and explained to me verbally. I hereby release and forever discharge and hold harmless MOW and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either law or in equity, which arise or may hereafter arise from my volunteer activities with MOW. *PHOTO RELEASE: I hereby grant and assign MOW all rights, title and interest in all photographic images and video or audio recordings that are made during my work with MOW.* Yes, I agree.

Signature*

Date* (E.g., 01/20/2020)

(Applicants - DO NOT FILL OUT THE FOLLOWING SECTION, IT IS FOR INTERVIEWERS ONLY) (Applicants - DO NOT FILL OUT THE FOLLOWING SECTION, IT IS FOR INTERVIEWERS ONLY) I am verifying that I am the interviewer for this volunteer applicant.

Date:

Approved: Approved: YES NO

Assigned to:

Start Date:

Day: Day: M T W Th F

Week: Week: 1, 3, 5 2, 4

Student Hours:

Date Leaving MOW:

Reason for Leaving:

Print Interviewer's Name:

Certificates Received:

Driver's License Verified: Driver's License Verified: YES NO

Notes: