Volunteer Sign up

First Name	* Required
Middle Name
Last Name	* Required
Address	* Required
Address 2
City	* Required
Zip	* Required
Please enter at least one phone number in this format (123) 456-7891
Home Phone
Cell Phone
Work Phone
Email	* Required
Please choose a login password	* Required
The following information is used only for reporting aggregate numbers to our funders For reporting purposes, your date of birth is important to us. Please enter as mm/dd/yyyy. Day field may be listed as '01'.
Birthday	* Required

Tell us about yourself	* Required

Are you Hispanic or Latino?	* Required
Gender	* Required

Primary Language Spoken	* Required
Are You a Veteran?	* Required
How did you hear about us?	* Required
If selecting Community Event, School, Presentation, or Other, please specify here:

Please enter an emergency contact in the text box. Enter the name, relation, address and contact phone number.	* Required
If you are enrolled as an Eras volunteer, you may be covered by supplementary accident and liability insurance, at no cost to you. Although this is not a substitute for your own insurance coverage, it covers you in case of personal injury to yourself or others while you are working at your assignment. Please designate your beneficiary.
Beneficiary Name	* Required
Beneficiary Phone Number	* Required

Are you employed outside of your home?
If yes, full time or part time
Retired?
Most recent employer
Job Title
Are you fulfilling Court Ordered Community Service?
Eras provides excess accident and auto liability insurance in addition to your insurance, which may cover you on your way to, during, and from volunteering with Eras. Our funding sources require that we have insurance information on file for ALL volunteers due to liability purposes.
Do you drive? Check the box if yes.
Do you have access to a reliable car? Check the box if yes.
Make - Model - Year of vehicle
Auto Insurance Company
Auto Policy #
Driver's License #
State of license issue
Do you have any driving restrictions?
If yes, what driving restrictions?
Community Clubs/Organization
Congregation Membership
Any additional skills (ex: fluent in another language, hobbies, music, etc.)
Please list two references
Reference 1: Name	* Required
Reference 1: Relationship	* Required
Reference 1: Phone Number	* Required
Reference 1: Email	* Required
Reference 2: Name
Reference 2: Relationship
Reference 2: Phone Number
Reference 2: Email

What is your availability? Choose your general availability and you can enter specific times below each day drop down
Availability: Monday
Specific availability: Monday
Availability: Tuesday
Specific availability: Tuesday
Availability: Wednesday
Specific availability: Wednesday
Availability: Thursday
Specific availability: Thursday
Availability: Friday
Specific availability: Friday
Availability: Saturday
Specific availability: Saturday
Availability: Sunday
Specific availability: Sunday
Any additional information?

Eras is a sponsor of the National Service Program, RSVP (Retired and Senior Volunteer Program). RSVP Volunteers focus on unmet needs in Milwaukee County and Waukesha County. By selecting "Yes" I am confirming that I am 55 or older and I agree to be a part of this program
I confirm	* Required
Please click the link below to open the Volunteer Handbook into a separate tab. After reading the handbook, please follow the instructions on the last page under Volunteer Agreement and Receipt of Handbook (Page 29). Eras Volunteer Handbook with Youth Protection Policy Volunteer Agreement: I understand that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information will result in denial or termination of volunteer activities and other penalties as provided under the law. I also understand that I am not an employee of Eras Senior Network, it's sponsors, stations, or the Federal Government and agree to serve without compensation. If you are 18 or older: I acknowledge that a criminal and driving background check and sex offender search will be performed to be considered as a volunteer with Eras Senior Network. I agree that any information regarding a client learned through conversations or contained in a client's file is confidential information. No information should be released to anyone (including family members) without proper authorization. Any volunteer that violates the confidentiality of any client will be terminated from volunteering at Eras Senior Network.
Volunteer Agreement (Agree/Disagree):	* Required
Date of Agreement:	* Required

Parental/Guardian Consent: I give my consent for my child named above to provide volunteer services to Eras Senior Network. (required if applicant is under 18 years of age)
Parental/Guardian Consent (If Applicable, Agree/Disagree):
Name of Parent/Guardian Agreeing to Consent (If Applicable):
Date of Parent/Guardian Consent (If Applicable):

Photo Consent: I, hereby give Eras Senior Network specific permission to: publish copyright, distribute and/or display photographic images of me taken throughout my volunteering. I release and discharge Eras Senior Network from any and all liability by virtue of distortion, blurring, alteration, optical illusion and/or use in composite form, whether the same is intentional, or otherwise.
Photo Consent (Agree/Disagree):	* Required
Date of Photo Consent:	* Required

Please leave this checkbox blank