Volunteer Application - Yakima & Selah Neighbors' Network

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth: (for background check) *

Home Phone

Cell Phone

Email *

Single Line Text

References (non-family)

Reference #1 Name *

First

Last

Relationship *

Phone *

Reference #2 Name *

First

Last

Relationship

Phone

Emergency Contact Information

*Preferably local

Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Additional Information

Availability - Please list preferred days of week and time of day *

Example: Monday and Wednesday mornings, Friday afternoons

Volunteer Interests: Please check ALL that apply. *

Please provide any other information that you think is relevant

Examples: Worked with blind people, master gardener, love of music, etc. Anything that would help match you to members.

Motor Vehicle Record Information

(only required for volunteers providing transportation)

Within the past 5 years, have you been ticketed for any of the following?

Upload a copy of insurance card for your vehicle

Click or drag a file to this area to upload.

Upload a copy of driver's license

Click or drag a file to this area to upload.

Release of Liability & Volunteer Agreement & Photo Release

By submitting this application, I affirm that the facts set forth in it are try and complete. By initialing statements below, I agree to the following YSNN policies:

I will offer my time without monetary compensation.

I understand that my own personal or professional business will not benefit financially or in any other way from the volunteer service that I will perform.

I agree to conform to all of the YSNN procedures and regulations.

I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in dismissal.

I authorize YSNN to contact my references and perform a background check

I agree to indemnify YSNN against and hold it harmless from all loss and expense arising out of any act, neglect or fault on my part.

I agree to fill out a volunteer service report within 2 days of each volunteer service

Finally, as a YSNN volunteer, I understand it is imperative to protect the confidentiality of all information pertaining to any YSNN member, non-member, volunteer or client associated with YSNN, including any identifying information about them, including the unauthorized possession, use, copying, reading or disclosure of applicable records, ledgers or files.

Submitting this form indicates your agreement to adhere to YSNN’s volunteer agreement if placed as a volunteer.

YSNN is not obligated to provide a placement, nor are you obligated to accept the position offered. The information you have submitted will not be given to any other parties without your permission.

Volunteers are covered through the state for industrial insurance (workman’s comp) and in order to report your hours and have you covered, your social security number is needed.

I have read the volunteer policies document and agree to its terms.

I certify that the information given on this form is accurate to the best of my knowledge.

Lastly, from time to time, YSNN may use still photos or video images of our members as well as volunteers for marketing the organization and/or on our website. May we use photographs taken of you while on volunteer duty? *

Yes
No

Signature *

First

Last

By typing your name, you are virtually signing this application.

Social Security Number (for L&I) *