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2. 

4. This enrollment application is for volunteers under age 55. Please complete all sections. If you are 55 or over please use the Retired & Senior Volunteer Program (RSVP) Application.

6. First Name*
7. Last Name*
8. Preferred / Nickname
10. Street Address
12. Address Line 2
14. City
15. State
16. Zip Code
18. Phone*
19. Cell Phone
21. Email
22. Date of Birth
    Date of Birth
26. Physical / Medical Limitations
28. Employment Experience
30. Special Skills / Interests / Languages
32. Volunteer Experience (Current, Past, Preferred)
34. Preferred Volunteer Program(s) you have interest in assisting with (if known)
36. Emergency Contact - First Name
37. Last Name
38. Relationship
39. Phone Number
43. Morning Availability

    1. Monday Morning
    2. Tuesday Morning
    3. Wednesday Morning
    4. Thursday Morning
    5. Friday Morning
    6. Saturday Morning
    7. Sunday Morning
44. Afternoon Availability

    1. Monday Afternoon
    2. Tuesday Afternoon
    3. Wednesday Afternoon
    4. Thursday Afternoon
    5. Friday Afternoon
    6. Saturday Afternoon
    7. Sunday Afternoon
46. More Info

    Please feel free to provide any additional information that might help us learn more about you, so that we can match you to the best volunteer opportunity.

48. The following demographic information is optional.

50. Gender

    1. Male
    2. Female
    3. Nonbinary
51. Race
52. Ethnicity

    1. Hispanic
    2. Non-Hispanic
54. Marital Status

    1. Single
    2. Married
    3. Divorced
    4. Widowed
55. Military

    1. Active
    2. Veteran
    3. None
56. Are any of your family members actively serving in the military?

    1. Yes
    2. No
60. Volunteer Agreement

    By checking "I Agree", I acknowledge that I have read and understand the following statements:

    Please note: Some of our programs require a background screening to be completed at no cost to you, such as our Home Delivered Meals program and Companion programs. If you have interest in either of these, you will be required to fill out an additional form for the program, and cannot begin until successful results have been received.

    I understand that in the case of an accident/injury to my person or property, my personal insurance carrier will be considered the primary insurance coverage. New Hanover County insurance coverage will be secondary and used only to cover expenses not covered with the primary insurance carrier.

62. Volunteer Agreement*

    1. I agree
64. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
66. Electronic Signature*
70. Photo Release Agreement

    I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to publish photographs taken of me, as well as my name and likeness, for use in the NHCSRC’s print, online and video-based marketing materials, as well as other Company publications.

    I hereby release and hold harmless NHCSRC from any reasonable expectation of privacy or confidentiality associated with the images specified above.

    I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

    I hereby release NHCSRC, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.

72. First Name*
73. Last Name*
74. Email*
76. Photo Release Agreement*

    1. Consent
    2. Decline

    You may either consent to or decline to release your photo rights as described above.

78. General Communication

    I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to contact me at the phone number(s) provided via SMS (text) message and communicate with me regarding volunteer duties, responsibilities, scheduling, and availability. I hereby release and hold harmless NHCSRC from any expectation of privacy or confidentiality associated with this communication. I understand that I can opt out from receiving text messages by texting ‘STOP’ as a reply. I further acknowledge normal cellular data and messaging rates may apply. The number of SMS (text) messages received will be limited and will generally not exceed more than 5 messages a month.

80. General SMS Message Acknowledgment Release*

    1. Consent
    2. Decline

    You may either consent to or decline to allow SMS (text) messaging as described above.

82. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
84. Electronic Signature*
88. Confidentiality Agreement

    The New Hanover County Senior Resource Center policy regarding confidentiality of citizen information is in accordance with laws which specifically address confidentiality (GS 130A-12, GS 130A-143, GS130A-212). All information concerning citizens is strictly confidential and should only be discussed or shared:

    • With those specifically authorized by written consent of the citizen, or others authorized to give consent for the citizen;
    • When necessary to provide appropriate care (within our agency) except as described in GS 130A-143;
    • Pursuant to subpoena or court order.

    Failure to observe the policy regarding confidentiality is reason for suspension or dismissal and may subject the employee, student, volunteer or contract worker to a lawsuit. All employees, students, volunteers, and contract workers will be required to sign a statement of understanding regarding this policy.

    • I understand that I may have direct or indirect access to confidential individually identifiable personal information (IIPI) in the course of performing my work activities.
      • Note: IIPI is any information collected from an individual that is created or received by the NHCSRC and relates to past, present or future contact, beneficiary, or individually identifiable information. Protected personal information (PPI) is IIPI in any form: paper, oral or electronic, that personally identifies an individual.
    • I agree to protect the confidential nature of all IIPI to which I have access and will not divulge this information to unauthorized persons.
    • I understand that there are state and federal laws and regulations that ensure the confidentiality of an individual’s identifying personal information.
    • I understand that there are New Hanover County Senior Resource Center (NHCSRC) policies and procedures with which I am required to comply related to the protection of IIPI.
    • I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.
    • I understand how I am expected to ensure the protection of IIPI. Should questions arise in the future about how to protect information to which I have access, I will immediately notify my supervisor and/or the NHCSRC Director.
    • I have been informed that this signed agreement will be retained on file for future reference.
90. First Name*
91. Last Name*
92. Email*
94. Consent*

    1. I agree to this confidentiality agreement.
96. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
98. Electronic Signature*
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit

* indicates a required field